Physician perspectives on delays in cancer diagnosis in Alberta: a qualitative study.

BACKGROUND: Delays in cancer diagnosis have been associated with reduced survival, decreased quality of life after treatment, and suboptimal patient experience. The objective of the study was to explore the perspectives of a group of family physicians and other specialists regarding potentially avoidable delays in diagnosing cancer, and approaches that may help expedite the process. METHODS: We conducted a qualitative study using interviews with physicians practising in primary and outpatient care settings in Alberta between July and September 2019. We recruited family physicians and specialists who were in a position to discuss delays in cancer diagnosis by email via the Cancer Strategic Clinical Network and the Alberta Medical Association. We conducted semistructured interviews over the phone, and analyzed data using thematic analysis. RESULTS: Eleven family physicians and 22 other specialists (including 7 surgeons or surgical oncologists, 3 pathologists, 3 radiologists, 2 emergency physicians and 2 hematologists) participated in interviews; 22 were male (66.7%). We identified 4 main themes describing 9 factors contributing to potentially avoidable delays in diagnosis, namely the nature of primary care, initial presentation, investigation, and specialist advice and referral. We also identified 1 theme describing 3 suggestions for improvement, including system integration, standardized care pathways and a centralized advice, triage and referral support service for family physicians. INTERPRETATION: These findings suggest the need for enhanced support for family physicians, and better integration of primary and specialty care before cancer diagnosis. A multifaceted and coordinated approach to streamlining cancer diagnosis is required, with the goals of enhancing patient outcomes, reducing physician frustration and optimizing efficiency.

Use Characteristics and Triage Acuity of a Digital Symptom Checker in a Large Integrated Health System: Population-Based Descriptive Study.

BACKGROUND: Pressure on the US health care system has been increasing due to a combination of aging populations, rising health care expenditures, and most recently, the COVID-19 pandemic. Responses to this pressure are hindered in part by reliance on a limited supply of highly trained health care professionals, creating a need for scalable technological solutions. Digital symptom checkers are artificial intelligence-supported software tools that use a conversational "chatbot" format to support rapid diagnosis and consistent triage. The COVID-19 pandemic has brought new attention to these tools due to the need to avoid face-to-face contact and preserve urgent care capacity. However, evidence-based deployment of these chatbots requires an understanding of user demographics and associated triage recommendations generated by a large general population. OBJECTIVE: In this study, we evaluate the user demographics and levels of triage acuity provided by a symptom checker chatbot deployed in partnership with a large integrated health system in the United States. METHODS: This population-based descriptive study included all web-based symptom assessments completed on the website and patient portal of the Sutter Health system (24 hospitals in Northern California) from April 24, 2019, to February 1, 2020. User demographics were compared to relevant US Census population data. RESULTS: A total of 26,646 symptom assessments were completed during the study period. Most assessments (17,816/26,646, 66.9%) were completed by female users. The mean user age was 34.3 years (SD 14.4 years), compared to a median age of 37.3 years of the general population. The most common initial symptom was abdominal pain (2060/26,646, 7.7%). A substantial number of assessments (12,357/26,646, 46.4%) were completed outside of typical physician office hours. Most users were advised to seek medical care on the same day (7299/26,646, 27.4%) or within 2-3 days (6301/26,646, 23.6%). Over a quarter of the assessments indicated a high degree of urgency (7723/26,646, 29.0%). CONCLUSIONS: Users of the symptom checker chatbot were broadly representative of our patient population, although they skewed toward younger and female users. The triage recommendations were comparable to those of nurse-staffed telephone triage lines. Although the emergence of COVID-19 has increased the interest in remote medical assessment tools, it is important to take an evidence-based approach to their deployment.

Current Recommendations for the Management of Stroke Patients in the Middle East in the Era of COVID-19 Pandemic; Statement from the MENA SINO.

COVID-19 pandemic has led to a change in the way we manage acute medical illnesses. This pandemic had a negative impact on stroke care worldwide. The World Stroke Organization (WSO) has raised concerns due to the lack of available care and compromised acute stroke services globally. The numbers of thrombolysis and thrombectomy therapies are declining. As well as, the rates and door-to treatment times for thrombolysis and thrombectomy therapies are increasing. The stroke units are being reallocated to serve COVID-19 patients, and stroke teams are being redeployed to COVID-19 centers. Covid 19 confirmed cases and deaths are rising day by day. This pandemic clearly threatened and threatening all stroke care achievements regionally. Managing stroke patients during this pandemic is even more challenging at our region. The Middle East and North Africa Stroke and Interventional Neurotherapies Organization (MENA-SINO) is the main stroke organization regionally. MENA-SINO urges the need to developing new strategies and recommendations for stroke care during this pandemic. This will require multiple channels of interventions and create a protective code stroke with fast triaging path. Developing and expanding the tele-stroke programs are urgently required. There is an urgent need for enhancing collaboration and cooperation between stroke expertise regionally and internationally. Integrating such measures will inevitably lead to an improvement and upgrading of the services to a satisfactory level.

Análise da conformidade dos atendimentos segundo Protocolo de Manchester em um Serviço de Urgência e Emergência / Conformity analysis of care according to the Manchester Protocol in an emergency and emergency service

Os serviços de urgência e emergência são um importante componente da assistência à saúde, mas a superlotação é o retrato do desequilíbrio entre a oferta e a procura. A avaliação do acolhimento com classificação de risco se apresenta como uma ferramenta que busca melhorar a qualidade e a segurança aos usuários e profissionais de saúde desse serviço, sendo recomendado o uso de protocolos preestabelecidos e validados para realizar a classificação de pacientes confere segurança tanto ao paciente quanto ao profissional de saúde. Na prática diária do enfermeiro que atua no setor de urgência e emergência, muitos são os momentos, durante a classificação de risco, em que o tempo não se faz suficiente para reconhecer a real demanda do cliente, seja decorrente do volume de pacientes e tipologia dos mesmos, seja pela dificuldade do protocolo de não permitir a identificação do fluxograma mais adequado. Esse estudo teve como objetivo identificar a conformidade dos atendimentos de pacientes classificados como urgentes pelo Protocolo de Manchester e o desfecho clínico. Estudo descritivo retrospectivo, quantitativo realizado no Serviço de urgência e emergência de um hospital geral, de grande porte e referência regional para atendimento de urgência e emergência, de uma cidade no interior de São Paulo. Os dados foram coletados de prontuários eletrônicos, no mês de junho/2017, e os atendimentos realizados aos pacientes classificados na cor amarela (urgentes) totalizaram 1.822 (42,7%), dos quais 954 atenderam ao critério de inclusão para o estudo. Dos prontuários analisados, 507 eram do sexo feminino e 69% (658) dos pacientes tinham menos de 60 anos de idade, com mediana de idade de 46 anos. O período de maior procura por atendimento correspondeu ao período diurno (das 7 às 19 horas), equivalente a 66,2% (632) dos atendimentos. O tempo mediano de espera entre a retirada da senha e o início da classificação de risco foi de 11 minutos; já o tempo mediano referente à duração da classificação de risco foi de 3 minutos; a mediana para o atendimento médico após a saída da classificação de risco foi de 5 minutos e o tempo mediano para finalização do desfecho médico foi de 142 minutos. Na análise dos desfechos, observou-se que 91% (868) dos pacientes desse grupo receberam alta após atendimento médico. A queixa mais prevalente foi de "problemas em extremidades" e o discriminador foi "dor moderada". A mediana de pacientes classificados por hora entre os enfermeiros foi de 13 pacientes, como sugerido pelo Protocolo de Manchester, e a concordância entre a classificação do paciente urgente feita pelo enfermeiro do serviço de urgência e emergência e pelo pesquisador foi de 84% (802). Este estudo identificou que os tempos de atendimentos para o grupo de pacientes classificados como urgentes foram considerados de acordo com a recomendação do protocolo. Um dos maiores desafios nos serviços de urgência e emergência refere-se a uma qualificação do processo de trabalho, de modo a garantir melhoria do cuidado prestado, redução dos tempos de espera para atendimentos e satisfação dos pacientes

Emergency and emergency services are an important component of health care, but overcrowding is the picture of the imbalance between supply and demand. The evaluation of the reception with risk classification is presented as a tool that seeks to improve the quality and safety of the users of this service. The use of pre-established and validated protocols to perform the classification of patients confers safety to both the patient and the health professional. In the daily practice of nurses working in the emergency and emergency sector, there are many moments during the risk classification where time is not enough to recognize the actual demand of the client, due to the volume of patients and the typology of the patients or because of the protocol's difficulty in not allowing the identification of the most adequate flowchart. The aim of this study was to identify the conformity of the care of patients classified as urgent by the Manchester Protocol and the clinical outcome. A descriptive, retrospective, quantitative study performed in the emergency and emergency department of a large general hospital and a regional reference for urgent and emergency care of a city in the interior of São Paulo. Data were collected from electronic medical records in June 2017, and the visits to patients classified as yellow (urgent) totaled 1,822 (42.7%), of which 954 met the inclusion criteria for the study. Of the records analyzed, 507 were female and 69% (658) of the patients were less than 60 years old, with a median age of 46 years. The period of greatest demand for care corresponded to the daytime period (from 7 am to 7 pm), equivalent to 66.2% (632) of the visits. The median waiting time between the withdrawal of the password and the start of the risk classification was 11 minutes; the median time for the duration of the risk classification was 3 minutes; the median for medical care after leaving the risk classification was 5 minutes and the median time for completion of the medical outcome was 142 minutes. In the analysis of the outcomes, it was observed that 91% (868) of patients in this group were discharged after medical care. The most prevalent complaint was "extremity problems" and the discriminator was "moderate pain". The median hourly rate among nurses was 13 patients, as suggested by the Manchester Protocol, and the concordance between the classification of the urgent patient by the emergency and emergency nurse and the researcher was 84% (802). This study identified that the times of care for the group of patients classified as urgent were considered according to the recommendation of the protocol. One of the greatest challenges in emergency and emergency services is a qualification of the work process, in order to guarantee improved care, reduction of waiting times for care and patient satisfaction

Pediatric triage education: An integrative literature review.

INTRODUCTION: The objective of this study was to review the currently published literature on the topic of pediatric triage education. METHOD: An integrative review of the literature was conducted using database searching and historical record review. RESULTS: A wide variety of pediatric triage educational methods exist, but studies with the highest-quality ratings most often used simulation programs or a standardized curriculum. Although there was a good deal of heterogeneity in terms of the outcomes measured, the accuracy of triage improved following educational interventions. DISCUSSION: Additional research is needed to compare different methods of pediatric triage education directly. Emergency nurses should be aware that pediatric triage is a high-risk event, and some educational methods may have advantages over others. In addition, although retention of pediatric triage skills is affected by the method and timing of pediatric triage education, emergency nurses should remain aware that improved pediatric triage skills could lead to improved pediatric outcomes, and target this as an area for further research.

Beyond guidelines: discretionary practice in face-to-face triage nursing.

This article draws on ethnographic data from a Norwegian emergency primary care clinic (EPCC) to explore nurses' discretionary application of guidelines. Specifically, it analyses nurses' discretionary use of the Manchester Triage System (MTS) when performing face-to-face triage, that is, assessing the urgency of patients' complaints. The analysis shows how nurses assessed patients at odds with MTS prescriptions by collecting supplementary data, engaging in differential diagnostic and holistic reasoning, relying on emotion and intuition, and allowing colleagues and patients to influence their reasoning. The findings also show how nurses' reasoning led them to override guidelines both overtly and covertly. Based on this evidence, it is argued that nurses' assessments relied more on internalised 'triage mindlines' than on codified triage guidelines, although the MTS did function as a support system, checklist and system for supervisory control. The study complements existing research on standardisation in nursing by providing an in-depth analysis of nurses' methods for navigating guidelines and by detailing how deviations from those guidelines spring from their clinical reasoning. The challenges of imposing a managerial logic on professional labour are also highlighted, which is of particular relevance in light of the drive towards standardisation in modern healthcare.

Validation of an emergency triage scale for obstetrics and gynaecology: a prospective study.

OBJECTIVE: To evaluate the reliability of a four-level triage scale for obstetrics and gynaecology emergencies and to explore the factors associated with an optimal triage. DESIGN: Thirty clinical vignettes presenting the most frequent indications for obstetrics and gynaecology emergency consultations were evaluated twice using a computerised simulator. SETTING: The study was performed at the emergency unit of obstetrics and gynaecology at the Geneva University Hospitals. SAMPLE: The vignettes were submitted to nurses and midwives. METHODS: We assessed inter- and intra-rater reliability and agreement using a two-way mixed-effects intra-class correlation (ICC). We also performed a generalised linear mixed model to evaluate factors associated triage correctness. MAIN OUTCOME MEASURES: Triage acuity. RESULTS: We obtained a total of 1191 evaluations. Inter-rater reliability was good (ICC 0.748; 95% CI 0.633-0.858) and intra-rater reliability was almost perfect (ICC 0.812; 95% CI 0.726-0.889). We observed a wide variability: the mean number of questions varied from 6.9 to 18.9 across individuals and from 8.4 to 16.9 across vignettes. Triage acuity was underestimated in 12.4% of cases and overestimated in 9.3%. Undertriage occurred less frequently for gynaecology compared with obstetric vignettes [odds ratio (OR) 0.45; 95% CI 0.23-0.91; P = 0.035] and decreased with the number of questions asked (OR 0.94; 95% CI 0.88-0.99; P = 0.047). Certification in obstetrics and gynaecology emergencies was an independent factor for the avoidance of undertriage (OR 0.35; 95% CI 0.17-0.70; P = 0.003). CONCLUSION: The four-level triage scale is a valid and reliable tool for the integrated emergency management of obstetrics and gynaecology patients. TWEETABLE ABSTRACT: The Swiss Emergency Triage Scale is a valid and reliable tool for obstetrics and gynaecology emergency triage.

Telehealth-Enabled Emergency Medical Services Program Reduces Ambulance Transport to Urban Emergency Departments.

INTRODUCTION: Emergency medical services (EMS) agencies transport a significant majority of patients with low acuity and non-emergent conditions to local emergency departments (ED), affecting the entire emergency care system's capacity and performance. Opportunities exist for alternative models that integrate technology, telehealth, and more appropriately aligned patient navigation. While a limited number of programs have evolved recently, no empirical evidence exists for their efficacy. This research describes the development and comparative effectiveness of one large urban program. METHODS: The Houston Fire Department initiated the Emergency Telehealth and Navigation (ETHAN) program in 2014. ETHAN combines telehealth, social services, and alternative transportation to navigate primary care-related patients away from the ED where possible. Using a case-control study design, we describe the program and compare differences in effectiveness measures relative to the control group. RESULTS: During the first 12 months, 5,570 patients participated in the telehealth-enabled program, which were compared against the same size control group. We found a 56% absolute reduction in ambulance transports to the ED with the intervention compared to the control group (18% vs. 74%, P<.001). EMS productivity (median time from EMS notification to unit back in service) was 44 minutes faster for the ETHAN group (39 vs. 83 minutes, median). There were no statistically significant differences in mortality or patient satisfaction. CONCLUSION: We found that mobile technology-driven delivery models are effective at reducing unnecessary ED ambulance transports and increasing EMS unit productivity. This provides support for broader EMS mobile integrated health programs in other regions.

Hospital Performance Indicators and Their Associated Factors in Acute Child Poisoning at a Single Poison Center, Central Saudi Arabia.

Admission rate and length of stay (LOS) are two hospital performance indicators that affect the quality of care, patients' satisfaction, bed turnover, and health cost expenditures. The aim of the study was to identify factors associated with higher admission rates and extended average LOS among acutely poisoned children at a single poison center, central Saudi Arabia.This is a cross-sectional, poison and medical chart review between 2009 and 2011. Exposures were child characteristics, that is, gender, age, body mass index (BMI), health history, and Canadian 5-level triage scale. Poison incident characteristics were, that is, type, exposure route, amount, form, home remedy, and arrival time to center. Admission status and LOS were obtained from records. Chronic poisoning, plant allergies, and venomous bites were excluded. Bivariate and regression analyses were applied. Significance at P < 0.05.Of the 315 eligible cases, (72%) were toddlers with equal gender distribution, (58%) had normal BMI, and (77%) were previously healthy. Poison substances were pharmaceutical drugs (63%) versus chemical products (37%). Main exposure route was oral (98%). Home remedy was observed in (21.9%), which were fluids, solutes, and/or gag-induced vomiting. Almost (52%) arrived to center >1 h. Triage levels: non-urgent cases (58%), less urgent (11%), urgent (18%), emergency (12%), resuscitative (1%). Admission rate was (20.6%) whereas av. LOS was 13 ±â€Š22 h. After adjusting and controlling for confounders, older children (adj.OR = 1.19) and more critical triage levels (adj.OR = 1.35) were significantly associated with higher admission rates compared to younger children and less critical triage levels (adj.P = 0.006) and (adj.P = 0.042) respectively. Home remedy prior arrival was significantly associated with higher av. LOS (Beta = 9.48, t = 2.99), compared to those who directly visited the center, adj.P = 0.003.Hospital administrators are cautioned that acutely poisoned children who received home remedies prior arrival are more likely to endure an extended LOS. This non-conventional practice is not recommended.

The Triaging and Treatment of Cold-Induced Injuries.

BACKGROUND: In Central Europe, cold-induced injuries are much less common than burns. In a burn center in western Germany, the mean ratio of these two types of injury over the past 10 years was 1 to 35. Because cold-induced injuries are so rare, physicians often do not know how to deal with them. METHODS: This article is based on a review of publications (up to December 2014) retrieved by a selective search in PubMed using the terms "freezing," "frostbite injury," "non-freezing cold injury," and "frostbite review," as well as on the authors' clinical experience. RESULTS: Freezing and cold-induced trauma are part of the treatment spectrum in burn centers. The treatment of cold-induced injuries is not standardized and is based largely on case reports and observations of use. distinction is drawn between non-freezing injuries, in which there is a slow temperature drop in tissue without freezing, and freezing injuries in which ice crystals form in tissue. In all cases of cold-induced injury, the patient should be slowly warmed to 22°-27°C to prevent reperfusion injury. Freezing injuries are treated with warming of the body's core temperature and with the bathing of the affected body parts in warm water with added antiseptic agents. Any large or open vesicles that are already apparent should be debrided. To inhibit prostaglandin-mediated thrombosis, ibuprofen is given (12 mg/kg body weight b.i.d.). CONCLUSION: The treatment of cold-induced injuries is based on their type, severity, and timing. The recommendations above are grade C recommendations. The current approach to reperfusion has yielded promising initial results and should be further investigated in prospective studies.

Adverse outcomes in maternity care for women with a low risk profile in The Netherlands: a case series analysis.

BACKGROUND: This study aimed to perform a structural analysis of determinants of risk of critical incidents in care for women with a low risk profile at the start of pregnancy with a view on improving patient safety. METHODS: We included 71 critical incidents in primary midwifery care and subsequent hospital care in case of referral after 36 weeks of pregnancy that were related to substandard care and for that reason were reported to the Health Care Inspectorate in The Netherlands in 36 months (n = 357). We performed a case-by-case analysis, using a previously validated instrument which covered five broad domains: healthcare organization, communication between healthcare providers, patient risk factors, clinical management, and clinical outcomes. RESULTS: Determinants that were associated with risk concerned healthcare organization (n = 20 incidents), communication about treatment procedures (n = 39), referral processes (n = 19), risk assessment by telephone triage (n = 10), and clinical management in an out of hours setting (n = 19). The 71 critical incidents included three cases of maternal death, eight cases of severe maternal morbidity, 42 perinatal deaths and 12 critical incidents with severe morbidity for the child. Suboptimal prenatal risk assessment, a delay in availability of health care providers in urgent situations, miscommunication about treatment between care providers, and miscommunication with patients in situations with a language barrier were associated with safety risks. CONCLUSIONS: Systematic analysis of critical incidents improves insight in determinants of safety risk. The wide variety of determinants of risk of critical incidents implies that there is no single intervention to improve patient safety in the care for pregnant women with initially a low risk profile.

Treatment pathways and quality improvement for patients with acute myocardial infarction at a tertiary care center.

The timely diagnosis and treatment of acute ST-segment elevation myocardial infarction (STEMI) have become paramount to improving outcomes in this population. Many states, including North Carolina, have established systems to guide regional emergency providers in caring for STEMI. We describe the current pathway for diagnosis and treatment of STEMI for providers referring patients to Duke University Hospital, including a system for expedited patient transport and activation of the cardiac catheterization laboratory from a wide referral base. There is also a structured process for review of cases and quality improvement, which incorporates physicians, administrators, and emergency medical personnel.

Barriers to the utilization of thrombolysis for acute ischaemic stroke.

WHAT IS KNOWN AND OBJECTIVE: Thrombolysis is currently the only evidence-based pharmacological treatment available for acute ischaemic stroke (AIS); however, its current utilization is suboptimal (administered to <3% of AIS patients). The aim of this article was to identify the potential barriers to the use of thrombolysis via a review of the available literature. METHODS: Medline, Embase, International Pharmaceutical Abstracts and Google Scholar were searched to identify relevant original articles, review papers and other literature published in the period 1995-2011. RESULTS AND DISCUSSION: Several barriers to the utilization of thrombolysis in stroke have been identified in the literature and can be broadly classified as 'preadmission' barriers and 'post-admission' barriers. Preadmission barriers include patient and paramedic-related factors leading to late patient presentation for treatment (i.e. outside the therapeutic time window for the administration of thrombolysis). Post-admission barriers include in-hospital factors, such as suboptimal triage of stroke patients and inefficient in-hospital acute stroke care systems, a lack of appropriate infrastructure and expertise to administer thrombolysis, physician uncertainty in prescribing thrombolysis and difficulty in obtaining informed consent for thrombolysis. Suggested strategies to overcome these barriers include public awareness campaigns, prehospital triage by paramedics, hospital bypass protocols and prenotification systems, urgent stroke-unit admission, on-call multidisciplinary acute stroke teams, urgent neuroimaging protocols, telestroke interventions and risk-assessment tools to aid physicians when considering thrombolysis. Additionally, greater pharmacists' engagement is warranted to help identify the people at risk of stroke and support preventative strategies, and provide the public with information regarding the recognition of stroke, as well as facilitate the access and use of thrombolysis. WHAT IS NEW AND CONCLUSION: The most effective interventions appear to be those comprising several strategies and those that target more than one barrier simultaneously. Therefore, optimal utilization of thrombolysis requires a systematic, integrated multidisciplinary approach across the continuum of acute care.

Is a STAS-based tool valid to triage patients at a specialist palliative care inpatient unit?

Many tools exist to assess the symptoms and needs of palliative care patients, but no tool has been validated to prioritise patients referred for specialist inpatient palliative care. The aim of this study was to produce and validate such a tool. A prospective pilot study produced a Support Team Assessment Schedule- (STAS-) based tool--the Admission Assessment Tool (AAT)--and compared this with the existing system of triage at the Marie Curie Hospice, Edinburgh. Validity of the tool was not confirmed and the tool was modified and re-evaluated. One hundred and twenty-seven consecutive patients referred to the hospice received three AAT scores: from the bed manager; the admitting doctor; and the admitting nurse. The hospice's multidisciplinary team assessed the urgency of each patient's admission. The overall correct classification rate was approximately two thirds, but false positive rates were high and there was poor inter-rate correlation. It is concluded the AAT has not been validated.

Psychosomatic medicine and biodefense preparedness--a new role for the American Psychosomatic Society.

Biodefense preparations in the United States have focused mostly on improving biosurveillance and hospital surge capacity in the event of an outbreak or a weapons of mass destruction (WMD) event. However, what if an invisible bioweapon or dirty bomb was released in a major population center, or if avian flu took hold with sustained human to human transmission? Suddenly, we need to combine efforts from psychosomatic medicine and general medicine with public health practice to triage nonexposed patients with somatic symptoms from those with medical sequelae resulting from hazardous exposures. This would better enable the limited acute care resources to be directed to those most in need of urgent medical care. Furthermore, psychosomatic medicine experts are potentially important players in biodefense planning related to risk communication and health education strategies in a WMD scenario or outbreak in which individuals must make informed choices about their need for immediate medical attention.