Application of telemedicine in the COVID-19 epidemic: An analysis of Gansu Province in China.

This paper analyzes the application of various telemedicine services in Gansu Province, China during the COVID-19 epidemic, and summarizes the experiences with these services. In addition, the satisfaction levels of patients and doctors with the application of telemedicine in COVID-19 were investigated, the deficiencies of telemedicine in Gansu were determined, and recommendations for modification were proposed. Coronavirus Disease 2019 (COVID-19) has broken out in China, and Gansu Province in Northwest of China has not been spared. To date, there are 91 local COVID-19 cases and 42 imported cases. 109 hospitals were selected as designated hospitals during the COVID-19 outbreak, and most of them were secondary hospitals. However, it was unsatisfactory that the ability of medical services is relatively low in most of secondary hospitals and primary hospitals. Therefore, we helped the secondary hospitals cope with COVID-19 by means of remote consultation, long-distance education, telemedicine question and answer (Q&A). Our practical experience shows that telemedicine can be widely used during the COVID-19 epidemic, especially in developing countries and areas with lagging medical standards.

Siamit: A Novel Academic-Tribal Health Partnership in Northwest Alaska.

PROBLEM: American Indians and Alaska Natives hold a state-conferred right to health, yet significant health and health care disparities persist. Academic medical centers are resource-rich institutions committed to public service, yet few are engaged in responsive, equitable, and lasting tribal health partnerships to address these challenges. APPROACH: Maniilaq Association, a rural and remote tribal health organization in Northwest Alaska, partnered with Massachusetts General Hospital and Harvard Medical School to address health care needs through physician staffing, training, and quality improvement initiatives. This partnership, called Siamit, falls under tribal governance, focuses on supporting community health leaders, addresses challenges shaped by extreme geographic remoteness, and advances the mission of academic medicine in the context of tribal health priorities. OUTCOMES: Throughout the 2019-2020 academic year, Siamit augmented local physician staffing, mentored health professions trainees, provided continuing medical education courses, implemented quality improvement initiatives, and provided clinical care and operational support during the COVID-19 pandemic. Siamit began with a small budget and limited human resources, demonstrating that relatively small investments in academic-tribal health partnerships can support meaningful and positive outcomes. NEXT STEPS: During the 2020-2021 academic year, the authors plan to expand Siamit's efforts with a broader social medicine curriculum, additional attending staff, more frequent trainee rotations, an increasingly robust mentorship network for Indigenous health professions trainees, and further study of the impact of these efforts. Such partnerships may be replicable in other settings and represent a significant opportunity to advance community health priorities, strengthen tribal health systems, support the next generation of Indigenous health leaders, and carry out the academic medicine mission of teaching, research, and service.

A National Pediatric Telepsychiatry Curriculum for Graduate Medical Education and Continuing Medical Education.

Objectives: Our goal was to develop an open access nationally disseminated online curriculum for use in graduate and continuing medical education on the topic of pediatric telepsychiatry to enhance the uptake of telepsychiatry among child psychiatry training programs and improve access to mental health care for youth and families. Methods: Following Kern's 6-stage model of curriculum development, we identified a core problem, conducted a needs assessment, developed broad goals and measurable objectives in a competency-based model, and developed educational content and methods. The curriculum was reviewed by experts and feedback incorporated. Given the urgent need for such a curriculum due to the COVID-19 pandemic, the curriculum was immediately posted on the American Academy of Child and Adolescent Psychiatry and American Association of Directors of Psychiatric Residency Training websites. Further evaluation will be conducted over the next year. Results: The curriculum covers the six areas of core competence adapted for pediatric telepsychiatry and includes teaching content and resources, evaluation tools, and information about other resources. Conclusion: This online curriculum is available online and provides an important resource and set of standards for pediatric telepsychiatry training. Its online format allows for ongoing revision as the telepsychiatry landscape changes.

Burden of an educational program on end of life management in a Internal Medicine ward: a real life report.

BACKGROUND AND AIM: Appropriate end of life (EOL) management in Internal Medicine wards is challanging. The aim of this study was to analyze the burden of an educational program on EOL management in a Internal Medicine ward. Materials and methods: We retrospectively analysed characteristics and management of patients consecutively died in an italian Internal Medicine ward along one year. We compared demographic, co-morbidity, pharmacological treatment in the last 48-hours of life and procedures during hospital stay in patients died six months before and after an educational program on palliative cares and EOL management addressed to a team of physicians and nurses. RESULTS: Study population was composed by 354 patients (190 females), with mean age ± DS 83.5 ± 10.6 years, one half admitted after the educational program. Eighty-four percent of deaths was exepected in the last 48 hours before exitus. Demographic characteristics and causes of hospitalization were not different before and after educational program. After the educational program the sharing of palliative care program with patient, relatives and/or caregivers (97.7% vs 85.8%, p=0.0001) and written order to withdrawal vital parameters relevation (39.5% vs 22%, p=0.0005) significantly increased, while difference in pharmacological classes prescribed in the last 48 hours of life was not find. Blood (54.8% vs 67.2%, p=0.0219) and arterial gas analysis (28.8% vs 39.5%, p=0.0435) samples in the last 48 hours of life were significantly reduced. Radiological and/or endoscopic examinations, red cells or platelets transfusion were reduced and palliative therapy was increased, despite difference between the two periods was not statistically significant. CONCLUSION: Educational program in Internal Medicine wards aimed to improve skills could contribute to make EOL management more appropriate and patient-oriented and it should be strongly encour-aged.

Implementation status of morbidity and mortality conferences in Austrian hospitals-A cross-sectional national survey study.

INTRODUCTION: Morbidity and mortality conferences (M&MCs) are an instrument for learning from past complications, unexpected follow-ups and deaths in hospitals and are important for improving patient safety. However, there are currently no quantitative data on the implementation of M&MCs in Austria. The aim of the study was to determine the status quo of the M&MCs in Austria. MATERIALS AND METHODS: A national cross-sectional study was conducted by means of a survey of 982 chief physicians of surgical disciplines, internal medicine, anesthesiology, intensive care, gynecology/obstetrics and pediatrics. The questionnaire focused on overall goals, structure and procedures of hospital M&MCs. RESULTS: Of the 982 contacted chief physicians, 314 (32.0%) completed the survey. Almost two thirds of the respondents, i.e. 203 (64.7%), had already implemented M&MCs. Of the 111 chief physicians who had not yet introduced M&MCs, 62 (55.9%) were interested in introducing such conferences in the future. Of the 203 respondents that had implemented M&MCs, 100 stated that their M&MC could be improved. They reported issues with "shame and blame" culture, hierarchical structures, too little knowledge about the capability of M&MC and, in particular, time constraints. Overall, the participating chief physicians showed that they are striving to improve their existing M&MCs. DISCUSSION/CONCLUSION: While we found a relatively high number of already implemented M&MCs we also identified a large heterogeneity in the format of the M&MCs. A highly structured M&MC including guidelines, checklists or templates does not only considerably improve its outcome but can also alleviate the main limiting factor which is the lack of time.

Building the Next Generation of Researchers: Mentored Training in Dissemination and Implementation Science.

PROBLEM: Dissemination and implementation (D&I) science provides the tools needed to close the gap between known intervention strategies and their effective application. The authors report on the Mentored Training for Dissemination and Implementation Research in Cancer (MT-DIRC) program-a D&I training program for postdoctoral or early-career cancer prevention and control scholars. APPROACH: MT-DIRC was a 2-year training institute in which fellows attended 2 annual Summer Institutes and other conferences and received didactic, group, and individual instruction; individualized mentoring; and other supports (e.g., pilot funding). A quasi-experimental design compared changes in 3 areas: mentoring, skills, and network composition. To evaluate mentoring and D&I skills, data from fellows on their mentors' mentoring competencies, their perspectives on the importance of and satisfaction with mentoring priority areas, and their self-rated skills in D&I competency domains were collected. Network composition data were collected from faculty and fellows for 3 core social network domains: contact, mentoring, and collaboration. Paired t tests (mentoring), linear mixed models (skills), and descriptive analyses (network composition) were performed. OUTCOMES: Mentors were rated as highly competent across all mentoring competencies, and each mentoring priority area showed reductions in gaps between satisfaction and importance between the 6 and 18 months post-first Summer Institute. Fellows' self-rated skills in D&I competencies improved significantly in all domains over time (range: 42.5%-52.9% increase from baseline to 18 months post-first Summer Institute). Mentorship and collaboration networks grew over time, with the highest number of collaboration network ties for scholarly manuscripts (n = 199) in 2018 and for research projects (n = 160) in 2019. NEXT STEPS: Building on study findings and existing literature, mentored training of scholars is an important approach for building D&I skills and networks, and thus to better applying the vast amount of available intervention evidence to benefit cancer control.

[There is no progress without school. Postgraduate specialization school completes the paradigm shift in palliative care.] / Non c'è progresso senza scuola. La Scuola di specializzazione completa il cambio di paradigma delle cure palliative.

With the conversion of law decree no. 34 of 19 May 2020, bearing urgent measures concerning health, support to work and the economy, as well as social policies related to CoViD-19 epidemiological emergency, thanks to the approval of an amendment to legislative decree "Rilancio" signed by Giorgio Trizzino, the Specialization school in medicine and palliative care will be established starting from a.y. 2021-2022. Additionally, a course in pediatric palliative care will be introduced in pediatrics specialization schools. The news has been welcomed with enthusiasm by the scientific community and the main stakeholders, some of which have made a strong contribution to this result: the Italian Society for Palliative Care, the Italian Federation for Palliative Care, the Maruzza Levebvre d'Ovidio Foundation, as well as the many professionals, institutions, and NPOs that have been supporting for the past forty years the progress of palliative care in Italy. An assessment of the impact of such a measure and its effects entails due process and contextualization in different areas: first of all, that of demand and current supply, followed by the historical-cultural, the social, and the normative.

The Economic and Clinical Impact of an Early Mobility Program in the Trauma Intensive Care Unit: A Quality Improvement Project.

Traumatic injury survivors often face a difficult recovery. Surgical and invasive procedures, prolonged monitoring in the intensive care unit (ICU), and constant preventive vigilance by medical staff guide standards of care to promote positive outcomes. Recently, patients with traumatic injuries have benefited from early mobilization, a multidisciplinary approach to increasing participation in upright activity and walking. The purpose of this project was to determine the impact of an early mobility program in the trauma ICU on length of stay (LOS), ventilator days, cost, functional milestones, and rehabilitation utilization. A quality improvement project compared outcomes and cost before and after the implementation of an early mobility program. The trauma team assigned daily mobility levels to trauma ICU patients. Nursing and rehabilitation staff collaborated to set daily goals and provide mobility-based interventions. Forty-four patients were included in the preintervention group and 43 patients in the early mobility group. Physical therapy and occupational therapy were initiated earlier in the early mobilization group (p = .044 and p = .026, respectively). Improvements in LOS, duration of mechanical ventilation, time to out-of-bed activity and walking, and discharge disposition were not significant. There were no adverse events related to the early mobility initiative. Activity intolerance resulted in termination of 7.1% of mobility sessions. The development and initiation of a trauma-specific early mobility program proved to be safe and reduce patient care costs. In addition, the program facilitated earlier initiation of physician and occupational therapies. Although not statistically significant, retrospective data abstraction provides evidence of fewer ICU and total hospital days, earlier extubations, and greater proactive participation in functional activities.

Advancing Complex Case Management Competencies in a Health Care System.

PURPOSE/OBJECTIVES: The purpose of this literature review is to evaluate evidence to support advanced education for hospital-based nurse case managers to address the discharge needs of medically complex patients who have extended hospital stays. PRIMARY PRACTICE SETTING: Acute care hospital and hospital systems. FINDINGS/CONCLUSION: Studies on hospital length of stay are prevalent as are studies of effective case management and the importance of a comprehensive education program. Correlating effective case management to successful disposition of long-stay patients and efficacy of discharge planning education is the focus of this review of evidence. Creation of advanced case management competency education will benefit patients, staff, and the health care system by increasing the skill level to promote early recognition of discharge barriers in complex long-stay patients. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Continued focus on affordability in health care will keep management of hospital length of stay high on the priority list. Pressure to create efficient patient management strategies leading to timely discharge disposition of medically complex patients through barrier mitigation and intervention requires effective case management tools.

Applying a mixed methods design for needs assessment of an international fellowship training program for Mongolian health professions.

PURPOSE: Continuing professional development is essential for improving health care services, especially in developing countries. Most of the training programs in Mongolia were not based on a targeted needs assessment. Therefore, we aimed to apply a mixed methods design to assess the training needs of Mongolian health professions. METHODS: We conducted a needs assessment using a convergent parallel mixed methods design in two steps. The survey and interview questions were developed to identify priority areas, targeted trainees, and effective training methods. A survey on 60 respondents, 15 individual interviews, and a focus group interview with 14 participants were conducted in the first step. In the second step, 12 representatives of key stakeholders were invited to a second focus group interview. RESULTS: Current health policy areas, areas related to future national plans, and areas not currently receiving governmental or international support were suggested as the main priorities. The stakeholder suggested that trainees should be selected based on their professional experience and language level, as well as each hospital's needs. Building teams including various professions, such as nurses, technicians, and biomedical engineers, was recommended as a way to exchange ideas with each other and to build teamwork for future collaboration. CONCLUSION: Medical training needs are dynamic and complex; therefore, a deep understanding of the context and setting is necessary. In this study, we assessed the targeted training needs of Mongolian health professions through a mixed methods design, which could be an effective way to conduct needs assessments for training programs.

Does Preexisting Practice Modify How Video Games Recalibrate Physician Heuristics in Trauma Triage?

BACKGROUND: A majority of severely injured patients fail to receive care at trauma centers (undertriage), in part, because of physician judgment. We previously developed two educational video games that reduced physicians' undertriage compared with control in two clinical trials. In this secondary analysis, we investigated heterogeneity of treatment effect of the interventions by assessing physicians' preexisting practice patterns in claims data. We hypothesized that physicians with high preexisting undertriage would benefit most from game-based training. METHODS: Using Medicare claims records from 2010 to 2015, we measured physicians' preexisting triage practices before their participation in one of two trials conducted in 2016 and 2017. We categorized physicians as having received game-based training versus control and noted their postintervention simulation triage performance in the trials. We used multivariable linear regression models to assess the heterogeneity of game-based training effect among physicians with high and low preexisting undertriage. RESULTS: Of the 394 eligible physicians from our trials, we identified 275 (70%) with claims for Medicare fee-for-service beneficiaries suffering severe injury between 2010 and 2015. On average, the physicians were 44 y old (SD 8.4) with 12 y (SD 8.2) of experience. We found significant interaction between preexisting practice and intervention efficacy (P = 0.04). Physicians with high undertriage before enrollment improved significantly with game-based training compared with the control (46% versus 63%, P < 0.001). Those with low preexisting undertriage did not (58% versus 56%, P = 0.76). CONCLUSIONS: Using claims-based data, we found heterogeneity of treatment effect of interventions designed to recalibrate physician heuristics. Physicians with high preexisting undertriage benefited most from game-based training.

The Impact of Case Management on Reducing Readmission for Patients Diagnosed With Heart Failure and Diabetes.

PURPOSE OF THE STUDY: To determine the impact of integrated case management services versus treatment as usual (TAU) for patients diagnosed with diabetes and concomitant heart failure. PRIMARY SETTING: This medical chart review was conducted at a single-site facility. The retrospective study design can be implemented at other facilities with a similar landscape. METHODS: A retrospective, descriptive, comparative analysis of integrated case management services compared with TAU from a medical chart review of 68 patients from September 1, 2015, through July 31, 2017. A medical chart review was conducted to generate the study sample for data collection and analysis. The data were organized, cleaned, and prepared and then analyzed. The data were analyzed using SPSS and verified with SAS and R. Applied were descriptive statistics and statistical tests-t test, χ test, Mann-Whitney U test, and Logistic Regression. RESULTS: For the integrated case management group, there were 18.4% who readmitted whereas 81.6% did not. For the TAU group, there were 52.6% who readmitted and 47.4% who did not. The association between readmission and case management was χ (1, n = 68) = 6.372, p = .012. NURSING IMPLICATIONS: Integrated case management services were statistically significant in reducing readmission for the sample. Demographics tested in this study were not significant predictors for readmission. Extending length of stay for patients who are not medically ready for discharge should be considered because there is a cost difference, as there is evidence of readmission reduction. Policy and procedural amendments can be obtained from this study.

Impact of Pharmacist-Driven Heart Failure in-Home Counseling on 30-Day Readmission Rates.

PURPOSE/OBJECTIVE: This study examines the impact of a pharmacist-driven intervention specific to heart failure patients with the goal of reducing readmission rates and improving quality of life in this population. FINDINGS/CONCLUSIONS: A total of 21 patients were included in the study. Twelve patients were female and 9 were male. The mean age was 76 years with a range of 65-93 years. Two of the 21 patients were readmitted within 30 days. One of the 2 readmitted patients died soon after admission was in the final stages of his or her disease and passed away soon after; it is unlikely for a home visit to have altered their path. This study did not meet the goal sample size due to some unforeseen limitations. However, the limited data that were obtained suggest a strong basis for further research. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: During a patient's transition in care from hospital to home, he or she is most vulnerable for complications and readmission. Intervention during this time will not only improve patient care and quality of life but also contribute to a notable cost savings for each prevented readmission. Pharmacist intervention, as part of the health care team, during this tenuous time has shown to make a valuable impact.

The design and conduct of Project RedDE: A cluster-randomized trial to reduce diagnostic errors in pediatric primary care.

BACKGROUND: Diagnostic errors contribute to the large burden of healthcare-associated harm experienced by children. Primary care settings involve high diagnostic uncertainty and limited time and information, creating ideal conditions for diagnostic errors. We report on the design and conduct of Project RedDE, a stepped-wedge, cluster-randomized controlled trial of a virtual quality improvement collaborative aimed at reducing diagnostic errors in pediatric primary care. METHODS: Project RedDE cluster-randomized pediatric primary care practices into one of three groups. Each group participated in a quality improvement collaborative targeting the same three diagnostic errors (missed diagnoses of elevated blood pressure and adolescent depression and delayed diagnoses of abnormal laboratory studies), but in a different sequence. During the quality improvement collaborative, practices worked both independently and collaboratively, leveraging general quality improvement strategies (e.g. process mapping) in addition to error-specific content (e.g. pocket guides for blood pressure norms) delivered during the intervention phase for each error. The quality improvement collaborative intervention included interactive learning sessions and webinars, quality improvement coaching at the team level, and repeated evaluation of failures via root cause analyses. Pragmatic data were collected monthly, submitted to a centralized data aggregator, and returned to the practices in the form of run charts comparing each practice's progress over time to that of the group. The primary analysis used patients as the unit of analysis and compared diagnostic error proportions between the intervention and baseline periods, while secondary analyses evaluated the sustainability of observed reductions in diagnostic errors after the intervention period ended. RESULTS: A total of 43 practices were recruited and randomized into Project RedDE. Eleven practices withdrew before submitting any data, and one practice merged with another participating practice, leaving 31 practices that began work on Project RedDE. All but one of the diverse, national pediatric primary care practices that participated ultimately submitted complete data. Quality improvement collaborative participation was robust, with an average of 63% of practices present on quality improvement collaborative webinars and 85% of practices present for quality improvement collaborative learning sessions. Complete data included 30 months of outcome data for the first diagnostic error worked on, 24 months of outcome data for the second, and 16 months of data for the third. LESSONS LEARNED AND LIMITATIONS: Contamination across study groups was a recurring concern; concerted efforts were made to mitigate this risk. Electronic health records played a large role in teams' success. CONCLUSION: Project RedDE, a virtual quality improvement collaborative aimed at reducing diagnostic errors in pediatric primary care, successfully recruited and retained a diverse, national group of pediatric primary care practices. The stepped-wedge, cluster-randomized controlled trial design allowed for enhanced scientific efficiency.