Screening for Quality of Life in a Neurology Tic Clinic Using Quality Improvement Methodology.

BACKGROUND: Tic disorders in children often co-occur with other disorders that can significantly impact functioning. Screening for quality of life (QoL) can help identify optimal treatment paths. This quality improvement (QI) study describes implementation of a QoL measure in a busy neurology clinic to help guide psychological intervention for patients with tics. METHODS: Using QI methodology outlined by the Institute for Healthcare Improvement, this study implemented the PedsQL Generic Core (4.0) in an outpatient medical clinic specializing in the diagnosis and treatment of tic disorders. Assembling a research team to design process maps and key driver diagrams helped identify gaps in the screening process. Conducting several plan-do-study-act cycles refined identification of patients appropriate to receive the measure. Over the three-year study, electronic health record notification tools and data collection were increasingly utilized to capture patients' information during their visit. RESULTS: Over 350 unique patients were screened during the assessment period. Electronic means replaced paper measures as time progressed. The percentage of patients completing the measure increased from 0% to 51.9% after the initial implementation of process improvement, advancing to 91.6% after the introduction of electronic measures. This average completion rate was sustained for 15 months. CONCLUSIONS: Using QI methodology helped identify the pragmatics of implementing a QoL assessment to enhance screening practices in a busy medical clinic. Assessment review at the time of appointment helped inform treatment and referral decisions.

Rhinosurgery during and after the COVID-19 Pandemic: International Consensus Conference Statement on Preliminary Perioperative Safety Measures.

BACKGROUND: The coronavirus disease of 2019 (COVID-19) pandemic has widely affected rhinosurgery, given the high risk of contagion and the elective nature of the aesthetic procedure, generating many questions on how to ensure safety. The Science and Research Committee of the Rhinoplasty Society of Europe aimed at preparing consensus recommendations on safe rhinosurgery in general during the COVID-19 pandemic by appointing an international panel of experts also including delegates of The Rhinoplasty Society. METHODS: A Zoom meeting was performed with a panel of 14 international leading experts in rhinosurgery. During 3.5 hours, four categories of questions on preoperative safety measures in private practice and outpatient clinics, patient assessment before and during surgery, and legal issues were presented by four chairs and discussed by the expert group. Afterward, the panelists were requested to express an online, electronic vote on each category and question. The panel's recommendations were based on current evidence and expert opinions. The resulting report was circulated in an iterative open e-mail process until consensus was obtained. RESULTS: Consensus was obtained in several important points on how to safely restart performing rhinosurgery in general. Preliminary recommendations with different levels of agreement were prepared and condensed in a bundle of safety measures. CONCLUSION: The implementation of the panel's recommendations may improve safety of rhinoplasty by avoiding operating on nondetected COVID-19 patients and minimizing severe acute respiratory syndrome coronavirus 2 virus spread in outpatient clinics and operating rooms.

Newly diagnosed seizures assessed at two established first seizure clinics: Clinic characteristics, investigations, and findings over 11 years.

Objective: 'First seizure' clinics (FSCs) aim to achieve early expert assessment for individuals with possible new-onset epilepsy. These clinics also have substantial potential for research into epilepsy evolution, outcomes, and costs. However, a paucity of FSCs details has implications for interpretation and utilization of this research. Methods: We reviewed investigation findings over 11 years (2000-2010) from two established independent FSCs at Austin Health (AH) and Royal Melbourne Hospital (RMH), Australia. These adult clinics are in major public hospitals and operate with similar levels of expertise. Organizational differences include screening and dedicated administration at AH. Included were N = 1555 patients diagnosed with new-onset unprovoked seizures/epilepsy (AH n = 901, RMH n = 654). Protocol-driven interviews and investigations had been recorded prospectively and were extracted from medical records for study. Results: Median patient age was 37 (IQR 26-52, range 18-94) years (AH 34 vs RMH 42 years; P < .001). Eighty-six percent of patients attended FSC within three weeks postindex seizure (median AH 12 vs RMH 25 days; P < .01). By their first appointment, 42% had experienced ≥2 seizures. An EEG was obtained within three weeks postindex seizure in 73% of patients, demonstrating epileptiform discharges in 25% (AH 33% vs RMH 15%). Seventy-six percent of patients had an MRI within 6 weeks. Of those with imaging (n = 1500), 19% had potentially epileptogenic abnormalities (RMH 28% vs AH 12%; P < .01). At both sites, changes due to previous stroke/hemorrhage were the commonest lesions, followed by traumatic brain injury. ≥WHO level 1 brain tumors diagnosed at presentation comprised a very small proportion (<1%) at each clinic. At both sites, epilepsy type could be determined in 60% of patients; RMH had more focal and AH more generalized epilepsy diagnoses. Significance: Differences between the clinics' administrative and screening practices may contribute to differences in investigation findings. Insight into these differences will facilitate interpretation and utilization, and planning of future research.

Feasibility of implementing a cervix cancer-specific patient-reported outcome measure in routine ambulatory clinics.

OBJECTIVE: To evaluate the implementation of a cervix cancer-specific patient-reported outcome measure, the European Organization for Research and Treatment of Cancer Quality of Life Cervical Cancer module (EORTC QLQ-CX24), into gynecologic oncology clinics. METHODS: This was a prospective, multi-institutional, cross-sectional study involving cervix cancer patients previously treated with curative intent radiotherapy who were attending routine follow-up appointments. Between January 2017 and August 2018, eligible patients were approached to complete the EORTC QLQ-CX24 prior to their clinical encounter and then review it with their oncologist. Patient and oncologist experience was evaluated using Feedback Questionnaires following the encounter. Descriptive statistics were used to summarize the results of the EORTC QLQ-CX24 and Feedback Questionnaires. Open-ended questions within the Feedback Questionnaires were analyzed to identify themes. RESULTS: Eighty-four patients consented to participate in the study. Of these, 80 (95.2%) completed the EORTC QLQ-CX24 and 76 (90.4%) completed both the EORTC QLQ-CX24 and the Feedback Questionnaires. There were high rates of completion for most items within the EORTC QLQ-CX24 (93-98%), except for items pertaining to vaginal symptoms and sexual health (34-35%). All eligible oncologists participated (n = 9). Overall, patients and oncologists positively endorsed use of the questionnaire during clinical encounters. The majority of patients (80%) and oncologists (89%) reported use of the questionnaire improved communication, including discussion of sensitive topics. Interestingly, only a minority of patients and oncologists stated a perceived preference for electronic completion (18% and 44%, respectively). CONCLUSION: Implementation of the EORTC QLQ-CX24 in gynecologic oncology clinics was feasible and acceptable according to patients and oncologists.

Resuming Breast Imaging Services in the Aftermath of the COVID-19 Pandemic: Safety and Beyond.

As the Coronavirus disease 2019 (COVID-19) epidemic begins to stabilize, different medical imaging facilities not directly involved in the COVID-19 epidemic face the dilemma of how to return to regular operation. We hereby discuss various fields of concern in resuming breast imaging services. We examine the concerns for resuming functions of breast imaging services in 2 broad categories, including safety aspects of operating a breast clinic and addressing potential modifications needed in managing common clinical scenarios in the COVID-19 aftermath. Using a stepwise approach in harmony with the relative states of the epidemic, health care system capacity, and the current state of performing breast surgeries (and in compliance with the recommended surgical guidelines) can ensure avoiding pointless procedures and ensure a smooth transition to a fully operational breast imaging facility.

Can Pediatric Orthopaedic Surgery be Done Safely in a Freestanding Ambulatory Surgery Center? Review of 3780 Cases.

BACKGROUND: The purpose of this study was to determine the intraoperative and 30-day postoperative complication rates in a large consecutive cohort of pediatric patients who had orthopaedic surgery at a freestanding ambulatory surgery center (ASC). The authors also wanted to identify the rates of same-day, urgent hospital transfers, and 30-day hospital admissions. The authors hypothesized that pediatric orthopaedic procedures at a freestanding ASC can be done safely with a low rate of complications. METHODS: A retrospective review identified patients aged 17 years or younger who had surgery at a freestanding ASC over a 9-year period. Adverse outcomes were divided into intraoperative complications, postoperative complications, need for the secondary procedure, unexpected hospital admission on the same day of the procedure, and unexpected hospital admission within 30 days of the index procedure. Complications were graded as grade 1, the complication could be treated without additional surgery or hospitalization; grade 2, the complication resulted in an unplanned return to the operating room (OR) or hospital admission; or grade 3, the complication resulted in an unplanned return to the OR or hospitalization with a change in the overall treatment plan. RESULTS: Adequate follow-up was available for 3780 (86.1%) surgical procedures. Overall, there were 9 (0.24%) intraoperative complications, 2 (0.08%) urgent hospital transfers, 114 (3%) complications, and 16 (0.42%) readmissions. Seven of the 9 intraoperative complications resolved before leaving the OR, and 2 required return to the OR.Neither complications nor hospitalizations correlated with age, race, gender, or length or type of surgery. There was no correlation between the presence of medical comorbidities, body mass index, or American Society of Anesthesiologists score and complication or hospitalization. CONCLUSIONS: Pediatric orthopaedic surgical procedures can be performed safely in an ASC because of multiple factors that include dedicated surgical teams, single-purpose ORs, and strict preoperative screening criteria. The rates of an emergency hospital transfer, surgical complications, and 30-day readmission, even by stringent criteria, are lower than those reported for outpatient procedures performed in the hospital setting. LEVEL OF EVIDENCE: Level IV-case series.

Reducing wait time for administration of systemic anticancer treatment (SACT) in a hospital outpatient facility.

The demand for systemic anticancer treatment continues to rise due to the increasing numbers being diagnosed with cancer and developments in treatment options. The net result is greater pressure on services and subsequent patient delays. Delays in treatment could decrease the benefit of the therapy and be detrimental to patient experience. Patients with human epidermal growth factor receptor-2 (HER 2) positive breast cancer within Raigmore Hospital waited an average of 41 min from the scheduled appointment time despite the administration of subcutaneous (SC) trastuzumab being scheduled for a 15 min treatment window. Given the frequency of these injections, this was having an adverse impact on patients and services. The aim of this project was for patients with breast cancer to receive treatment within the 15 min window. Lean principles were applied to reduce waste and increase value. Exploration of the problem led to the solution of relocating the administration of SC trastuzumab from the Macmillan Day Bed Unit (MDBU) to the Highland Breast Centre (HBC). Multiple improvement tools and techniques were used to implement the change. Data were collected on the median number of treatment episodes of SC trastuzumab per week at baseline and patient wait from appointment time to treatment completion was calculated at baseline and as an ongoing measure. Patient experience feedback was gathered following relocation of the treatment. Following relocation, the average time from scheduled appointment to discharge was 14 min (66% reduction). Patient experience feedback was positive and identified an unanticipated outcome; the regular Friday afternoon clinic, identified as most efficient for the service, was found by patients to be particularly convenient for their own planning. Through the application of Lean principles, the service was redesigned in a cost neutral way and resulted in a reduction in the wait time for treatment.

Medical and socioeconomic challenges of private dermatocosmetology clinics during COVID-19 pandemic: A survey from Turkey.

BACKGROUND: Coronavirus 2019 (COVID-19) disease has rapidly spread worldwide with a multitude effects on daily life. Since the transmission risk increases with close contact, some cosmetic procedures are considered high risk and majority of them had to be postponed or canceled in private dermatocosmetology clinics especially during the heavy period of the outbreak. AIMS: We aimed to document the medical and socioeconomic problems emerged in dermatocosmetology clinics in Turkey caused by COVID-19 pandemic and to discuss the management strategies taken by dermatologists. PATIENTS/METHODS: This survey research was conducted with 100 dermatologists who work in private dermatocosmetology clinics. The survey included 38 questions about office re-arrangements including patient admission and office environment, safety precautions taken for cosmetic procedures, management of clinic staff, and financial impact of the pandemic. RESULTS: A remarkable decrease in major cosmetic interest was reported in private clinics; meanwhile, there was an increase in applicants for noncosmetic dermatological complaints. The most avoided cosmetic procedures were application of skin care devices, lasers, chemical peeling, and thread lifting, while botulinum toxin injection was the most performed procedure. Nearly half of the participants had severe financial damage. Of the participants, 55% reported that they worked anxiously during this period and 60% believed that they managed the early period of the pandemic successfully. CONCLUSION: Private dermatocosmetology clinics have to work in a totally different period that they have never experienced before. The pandemic has had serious impacts on both medical and socioeconomic issues which had to be managed carefully.

Patient-reported outcomes collected in ambulatory oncology practices: Feasibility, patterns, and correlates.

OBJECTIVE: To examine the feasibility of soliciting outcomes from adults who received chemotherapy treatment for cancer and describe the patterns and correlates of patient-reported toxicities. DATA SOURCES: Patient survey data from 29 Michigan ambulatory oncology practices collected in 2017. STUDY DESIGN: Secondary analysis of patient survey data. Descriptive statistics were generated at the patient and practice levels. Thematic analysis of open-text comments identified clusters of frequently reported toxicities. DATA COLLECTION METHODS: Patients completed 11 items from the Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events. Using a 5-point Likert scale, patients rated the frequency of nausea, vomiting, diarrhea, and pain; the severity of nausea, vomiting, constipation, numbness/tingling, and pain; and how much numbness/tingling and pain interfered with usual or daily activities. Patients could also report two toxicities in open-text comments. Finally, patients reported unplanned health care service for toxicity or side effect management. PRINCIPAL FINDINGS: Of 3565 eligible patients, 2245 participated (63%) and 457 (20%) rated at least one toxicity as severe/very severe. Across practices, the proportion of patients who reported at least one severe/very severe toxicity ranged from 8% to 50%. Troubling toxicities included pain frequency (mean 2.3, SD 1.3), pain severity (2.1, 1.1), and diarrhea frequency (1.9, 1.0). From completed assessments, 1653 (74%) reported at least one toxicity in open-text comments; fatigue (n = 182), stomach discomfort (n = 53), and skin/nail changes (n = 41) were most frequently reported. Regarding consequences, 156 patients (7%) reported unplanned health care service use: 41 (26%) visited an emergency department and 32 (21%) were admitted to a hospital. CONCLUSIONS: Querying patients on chemotherapy treatment experiences and toxicities was feasible. Toxicity rates varied across practices, which informed quality improvement. Toxicity severity and service use incidence exceed previously published trial data, particularly for pain, fatigue, and gastrointestinal issues. Open-text questions enabled exploration with newer treatment regimens.

Consenso argentino en gestión efectiva de clínicas de anticoagulación para uso de antagonistas de la vitamina K / Argentine consensus in effective management of anticoagulation clinics for the use of vitamin K antagonists

Resumen El tratamiento de un paciente anticoagulado con antagonistas de la vitamina K (AVK) sigue siendo un desafío, especialmente en regiones donde, por el costo, los dicumarínicos son todavía la alternativa más buscada a la hora de elegir un anticoagulante oral. Las clínicas de anticoagulación han demostrado ser la forma más eficiente y segura de evitar complicaciones trombóticas y hemorrágicas y de mantener al paciente en rango óptimo de tratamiento. Sin embargo, requieren de una adecuada infraestructura y personal capacitado para que funcionen eficientemente. En este consenso argentino se propone una serie de parámetros para la gestión efectiva de una clínica de anticoagulación. El objetivo es lograr una elevada calidad desde el punto de vista clínico-asistencial a través de un laboratorio de hemostasia de excelencia. Los criterios desarrollados en el documento fueron consensuados por un amplio grupo de expertos especialistas en hematología y en bioquímica de todo el país. Estos criterios deben adaptarse a la irregular disponibilidad de recursos de cada centro, pero siempre se los debe tener en cuenta a la hora de indicar el tratamiento anticoagulante con estas drogas. Tener en consideración estas premisas nos permitirá optimizar la atención del enfermo anticoagulado con AVK y de esta forma minimizar las intercurrencias trombóticas y hemorrágicas a las que está expuesto, para así honrar nuestra promesa de no dañar al paciente.

Abstract Treating an anticoagulated patient with vitamin K antagonists (VKA) remains a challenge, especially in areas where dicoumarins are still the first drug of choice due to the cost of other oral anticoagulants. Anticoagulation clinics have proven to be the most efficient and safe way to avoid thrombotic and hemorrhagic complications and to keep patients in optimal treatment range. However, they require adequate infrastructure and trained personnel to work properly. In this Argentine consensus we propose a series of guidelines for the effective management of the anticoagulation clinics. The goal is to achieve the excellence in both the clinical healthcare and the hemostasis laboratory for the anticoagulated patient. The criteria developed in the document were agreed upon by a large group of expert specialists in hematology and biochemistry from all over the country. The criteria presented here must always be considered when indicating VKA although they had to be adapted to the unequal reality of each center. Taking these premises into consideration will allow us to optimize the management of the anticoagulated patient with VKA and thus minimize thrombotic and hemorrhagic intercurrences, in order to honor our promise not to harm the patient.

Different models of pharmaceutical services and care in primary healthcare clinics in the Eastern Cape, South Africa: Challenges and opportunities for pharmacy practice.

BACKGROUND: Primary health care (PHC) re-engineering forms a crucial part of South Africa's National Health Insurance (NHI), with pharmaceutical services and care being crucial to treatment outcomes. However, owing to a shortage of pharmacists within PHC clinics, task-shifting of the dispensing process to pharmacist's assistants and nurses is common practice. The implications of this task-shifting process on the provision of pharmaceutical services and care remains largely unstudied. AIM: The study aimed to explore the pharmacist-based, pharmacist's assistant-based and nurse-based dispensing models within the PHC setting. SETTING: The Nelson Mandela Bay Health District, South Africa. METHODS: A mixed methods approach was utilised comprising of Phase 1: a pharmaceutical services audit to analyse pharmaceutical service provision and Phase 2: semi-structured interviews to describe the pharmaceutical care provision within each dispensing model thematically. RESULTS: Pharmaceutical services partially fulfilled minimum standards within all models, however, challenges exist that limit the quality of these services. Phase 2 showed that the provision of pharmaceutical care within all models was restricted by context-related constraints, thus patient-centred activities to underpin pharmaceutical services were limited. CONCLUSION: Although pharmaceutical services may have been available for all models, compromised quality of these services impacted overall quality of care. Limited pharmaceutical care provision was evident within each dispensing model. The results raised concerns about the current utilisation of pharmacy personnel, including the pharmacist, within the PHC setting. Further opportunities exist, if constraints allow, for the pharmacist to contribute to better patient-centred care.

Policy context, coherence and disjuncture in the implementation of the Ideal Clinic Realisation and Maintenance programme in the Gauteng and Mpumalanga provinces of South Africa.

BACKGROUND: Universal health coverage is a key target of the Sustainable Development Goals and quality of care is fundamental to its attainment. In South Africa, the National Health Insurance (NHI) system is a major health financing reform towards universal health coverage. The Ideal Clinic Realisation and Maintenance (ICRM) programme aims to improve the quality of care at primary healthcare level in preparation for NHI system implementation. This study draws on Bressers' Contextual Interaction Theory to explore the wider, structural and specific policy context of the ICRM programme and the influence of this context on policy actors' motivation, cognition and perceived power. METHODS: This was a nested qualitative study, conducted in two NHI pilot districts in the Gauteng and Mpumalanga Provinces of South Africa. Following informed consent, we conducted in-depth interviews with key informants involved in the conceptualisation and implementation of the ICRM programme. The questions focused on ICRM policy context, rationale and philosophy, intergovernmental relationships, perceptions of roles and responsibilities in implementation, ICRM programme resourcing, and implementation progress, challenges and constraints. We used thematic analysis, informed by Bressers' theory, to analyse the data. RESULTS: A total of 36 interviews were conducted with key informants from national, provincial and local government. The wider context of the ICRM programme implementation was the drive to improve the quality of care at primary healthcare level in preparation for NHI. However, the context was characterised by contestations about the roles and responsibilities of the three government spheres and weak intergovernmental relationships. Notwithstanding examples of strong local leadership, the disjuncture between two national quality of care initiatives and resource constraints influenced policy actors' experiences and perceptions of the ICRM programme. They expressed frustrations about the lack of or diffuse accountability and their lack of involvement in decision-making, thus questioning the sustainability of the ICRM programme. CONCLUSIONS: National health sector reforms should consider the context of policy implementation and potential impact on actors' motivation, cognition and power. All relevant policy actors should be involved in policy design and implementation. A clear communication strategy and ongoing monitoring and evaluation are prerequisites for implementation success.

Air care: an 'aerography' of breath, buildings and bugs in the cystic fibrosis clinic.

With significant relevance to the Covid-19 pandemic, this paper contributes to emerging 'aerographic' research on the socio-materialities of air and breath, based on an in-depth empirical study of three hospital-based lung infection clinics treating people with cystic fibrosis. We begin by outlining the changing place of atmosphere in hospital design from the pre-antibiotic period and into the present. We then turn to the first of three aerographic themes where air becomes a matter of grasping and visualising otherwise invisible airborne infections. This includes imagining patients located within bodily spheres or 'cloud bodies', conceptually anchored in Irigaray's thoughts on the 'forgetting of the air' and Sloterdijk's immunitary 'spherology' of the body. Our second theme explores the material politics of air, air conditioning, window design and the way competing 'air regimes' come into conflict with each other at the interface of buildings, bodies and the biotic. Our final theme attends to the 'cost of air', the aero-economic problem of atmospheric scarcity within modern high-rise, deep-density healthcare architectures.

Level of adult client satisfaction with clinic flow time and services of an integrated non-communicable disease-HIV testing services clinic in Soweto, South Africa: a cross-sectional study.

BACKGROUND: While HIV Testing Services (HTS) have increased, many South Africans have not been tested. Non-communicable diseases (NCDs) are the top cause of death worldwide. Integrated NCD-HTS could be a strategy to control both epidemics. Healthcare service strategies depends partially on positive user experience. We investigated client satisfaction of services and clinic flow time of an integrated NCD-HTS clinic. METHODS: This prospective, cross-sectional study evaluated HTS client satisfaction with an HTS clinic at two phases. Phase 1 (February-June 2018) utilised standard HTS services: counsellor-led height/weight/blood pressure measurements, HIV rapid testing, and symptoms screening for sexually transmitted infections/Tuberculosis. Phase 2 (June 2018-March 2019) further integrated counsellor-led obesity screening (body mass index/abdominal circumference measurements), rapid cholesterol/glucose testing; and nurse-led Chlamydia and human papilloma virus (HPV)/cervical cancer screening. Socio-demographics, proportion of repeat clients, clinic flow time, and client survey data (open/closed-ended questions using five-point Likert scale) are reported. Fisher's exact test, chi-square analysis, and Kruskal Wallis test conducted comparisons. Multiple linear regression determined predictors associated with clinic time. Content thematic analysis was conducted for free response data. RESULTS: Two hundred eighty-four and three hundred thirty-three participants were from Phase 1 and 2, respectively (N = 617). Phase 1 participants were significantly older (median age 36.5 (28.0-43.0) years vs. 31.0 (25.0-40.0) years; p = 0.0003), divorced/widowed (6.7%, [n = 19/282] vs. 2.4%, [n = 8/332]; p = 0.0091); had tertiary education (27.9%, [n = 79/283] vs. 20.1%, [n = 67/333]; p = 0.0234); and less female (53.9%, [n = 153/284] vs 67.6%, [n = 225/333]; p = 0.0005), compared to Phase 2. Phase 2 had 10.2% repeat clients (n = 34/333), and 97.9% (n = 320/327) were 'very satisfied' with integrated NCD-HTS, despite standard HTS having significantly shorter median time for counsellor-led HTS (36.5, interquartile range [IQR]: 31.0-45.0 vs. 41.5, IQR: 35.0-51.0; p < 0.0001). Phase 2 associations with longer clinic time were clients living together/married (est = 6.548; p = 0.0467), more tests conducted (est = 3.922; p < 0.0001), higher overall satisfaction score (est = 1.210; p = 0.0201). Those who matriculated experienced less clinic time (est = - 7.250; p = 0.0253). CONCLUSIONS: It is possible to integrate counsellor-led NCD rapid testing into standard HTS within historical HTS timeframes, yielding client satisfaction. Rapid cholesterol/glucose testing should be integrated into standard HTS. Research is required on the impact of cervical cancer/HPV screenings to HTS clinic flow to determine if it could be scaled up within the public sector.

Returning to orthopaedic business as usual after COVID-19: strategies and options.

PURPOSE: The aim of this manuscript is to review the available strategies in the international literature to efficiently and safely return to both normal orthopaedic surgical activities and to normal outpatient clinical activities in the aftermath of a large epidemic or pandemic. This information would be beneficial to adequately reorganize outpatient clinics and hospitals to provide the highest possible level of orthopaedic care to our patients in a safe and efficient manner. METHODS: A literature search was performed for relevant research articles. In addition, the World Health Organisation (WHO), the US Centers for Disease Control (CDC), American Association of Orthopaedic Surgeons (AAOS), the EU CDC and other government health agency websites were searched for any relevant information. In particular, interest was paid to strategies and advise on managing the orthopaedic patient flow during outpatient clinics as well as surgical procedures including the necessary safety measures, while still providing a high-quality patient experience. The obtained information is provided as a narrative review. RESULTS: There was not any specific literature concerning the organization of an outpatient clinic and surgical activities and the particular challenges in dealing with a high-volume practice, in the afterwave of a pandemic. CONCLUSION: As the COVID-19 crisis has abruptly halted most of the orthopaedic activities both in the outpatient clinic and the operating room, a progressive start-up scenario needs to be planned. The exact timing largely depends on factors outside of our control. After restrictions will be lifted, clinical and surgical volume will progressively increase. This paper offers key points and possible strategies to provide the highest level of safety to both the orthopaedic patient and the orthopaedic team including administrative staff and nurses, during the start-up phase. LEVEL OF EVIDENCE: Review, Level V.

Lessons learned from an evaluation of referrals to the emergency department.

BACKGROUND: Emergency department (ED) crowding is an international phenomenon dependent on input, throughput, and output factors. This study aims to determine whether patterns of potentially unnecessary referrals from either primary care physicians (PCPs) or urgent care centers (UCCs) can be identified, thereby to reduce ED visits by patients who could be treated elsewhere. Literature from the United States reports up to 35% unnecessary referrals from UCCs. METHODS: A retrospective cohort study was conducted of patients referred to an ED in Jerusalem by either their PCP or a group of UCCs with a full range of laboratory tests and basic imaging capabilities between January 2017 and December 2017. The data were analyzed to identify referrals involving diagnoses, specialist consultations, and examinations unavailable in the PCP's office or UCC (e.g., ultrasound, CT, echocardiogram, or stress test); these referrals were considered necessary for completion of the patient work-up. If patients were evaluated by an ED physician and sent home after an examination or laboratory test available at least in the UCC, the referrals were considered potentially unnecessary. RESULTS: Significantly more referrals were made by PCPs than UCCs (1712 vs. 280, p < 0.001). Significant differences were observed for orthopedics, general surgery, and obstetrics/gynecology referrals (p = 0.039, p < 0.001, p = 0.003). A higher percentage of patients referred by PCPs had potentially unnecessary visits compared to patients referred by UCCs (13.9% vs. 7.9%, p = 0.005). CONCLUSION: A robust UCC system may help further reduce potentially unnecessary visits (including complex patients) to the ED.

Implementing Daily Management Systems to Support Sustained Quality Improvement in Ambulatory Surgery Centers.

Quality improvement processes and management approaches that provide a foundation for continuous quality improvement can lead to improved patient care. The Institute for Healthcare Improvement developed a high-performance management system (HPMS) for health care leaders and staff members to effect continuous quality control, and then conducted a pilot of the system in several ambulatory surgery centers (ASCs). The primary focus of the pilot program in the ASC setting was to understand the applicability of the theory of quality control using related practices (eg, standardized daily huddles, visual management boards) included in the modified HPMS. After implementing the new program, pilot site leaders observed an improvement of approximately 10 percentage points in their Agency for Healthcare Research and Quality patient safety culture survey scores. At the end of the pilot, the researchers concluded that ASC leaders can improve patient care and sustain improvement in their organizations using the HPMS practices.