Compliance with recommended cancer patient pathway timeframes and choice of treatment differed by cancer type and place of residence among cancer patients in Norway in 2015-2016.

BACKGROUND: Cancer patient pathways (CPPs) were implemented in Norway to reduce unnecessary waiting times, regional variations, and to increase the predictability of cancer care for the patients. This study aimed to determine if 70% of cancer patients started treatment within the recommended time frames, and to identify potential delays. METHODS: Patients registered with a colorectal, lung, breast, or prostate cancer diagnosis at the Cancer Registry of Norway in 2015-2016 were linked with the Norwegian Patient Registry and Statistics Norway. Adjusting for sociodemographic variables, multivariable quantile (median) regressions were used to examine the association between place of residence and median time to start of examination, treatment decision, and start of treatment. RESULTS: The study included 20 668 patients. The proportions of patients who went through the CPP within the recommended time frames were highest among colon (84%) and breast (76%) cancer patients who underwent surgery and lung cancer patients who started systemic anticancer treatment (76%), and lowest for prostate cancer patients who underwent surgery (43%). The time from treatment decision to start of treatment was the main source of delay for all cancers. Travelling outside the resident health trust prolonged waiting time and was associated with a reduced odds of receiving surgery and radiotherapy for lung and rectal cancer patients, respectively. CONCLUSIONS: Achievement of national recommendations of the CCP times differed by cancer type and treatment. Identified bottlenecks in the pathway should be targeted to decrease waiting times. Further, CPP guidelines should be re-examined to determine their ongoing relevance.

Evaluation and management of traumatic pneumothorax: A Western Trauma Association critical decisions algorithm.

ABSTRACT: This is a recommended algorithm of the Western Trauma Association for the management of a traumatic pneumothorax. The current algorithm and recommendations are based on available published prospective cohort, observational, and retrospective studies and the expert opinion of the Western Trauma Association members. The algorithm and accompanying text represents a safe and reasonable approach to this common problem. We recognize that there may be variability in decision making, local resources, institutional consensus, and patient-specific factors that may require deviation from the algorithm presented. This annotated algorithm is meant to serve as a basis from which protocols at individual institutions can be developed or serve as a quick bedside reference for clinicians. LEVEL OF EVIDENCE: Consensus algorithm from the Western Trauma Association, Level V.

Polypharmacy among pediatric cancer patients dying in the hospital.

BACKGROUND: Decisions on medication treatment in children dying from cancer are often complex and may result in polypharmacy and increased medication burden. There is no information on medication burden in pediatric cancer patients at the end of life (EOL). OBJECTIVES: To characterize medication burden during the last hospitalization in children dying from cancer. METHODS: We performed a retrospective cohort study based on medical records of 90 children who died from cancer in hospital between 01 January 2010 and 30 December 2018. Demographic and clinical information were collected for the last hospitalization. We compared medication burden (number of medication orders) at hospitalization and at time of death and examined whether changes in medication burden were associated with clinical and demographic parameters. RESULTS: Median medication burden was higher in leukemia/lymphoma patients (6 orders) compared to solid (4 orders) or CNS tumor patients (4 orders, P = 0.006). Overall, the median number of prescriptions per patient did not change until death (P = 0.42), while there was a significant reduction for some medication subgroups (chemotherapy [P = 0.035], steroids [P = 0.010]).Patients dying in the ICU (n=15) had a higher medication burden at death (6 orders) than patients dying on wards (3 orders, P = 0.001). There was a trend for a reduction in medication burden in patients with "Do not resuscitate" (DNR) orders (P = 0.055). CONCLUSIONS: Polypharmacy is ubiquitous among pediatric oncology patients at EOL. Disease type and DNR status may affect medication burden and deprescribing during the last hospitalization.

Association of kidney functions with a cascade of care for diabetes and hypertension in two geographically distinct Indian cohorts.

AIM: Type 2 diabetes (T2DM) and hypertension (HTN) are the main modifiable risk factors of chronic kidney disease (CKD), among the known traditional and non-traditional risk factors. METHODS: We determined the prevalence and care-cascade of these modifiable CKD-risk factors and their association with socioeconomic status in adjoining Lucknow and Puducherry cities of India. RESULTS: 439 participants reported no CKD were recruited. Serum analysis revealed an Estimated Glomerular Filtration Rate (eGFR) ≥ 90 ml/min/1.73 m2 in 60.36% of the population. Of them, 55.85% had HTN and/or T2DM as CKD-risk factors; however, less than half of this population was unaware of their CKD-risk status. Awareness and treatment were significantly higher in Puducherry and were associated with literacy, occupation, and residence place. Although the CKD-risk population was about two times higher in Puducherry than Lucknow, the populations with mild-low eGFR were comparable in the two regions. Moreover, in Lucknow, mild-low eGFR and low awareness were more prevalent among the younger participants (<30 years), relative to Puducherry. CONCLUSIONS: Despite a higher prevalence of CKD-risk factors in Puducherry, populations with mild-low eGFR were comparable to Lucknow. More heightened awareness and better care cascade for CKD-risk factors in Puducherry may prevent or delay eGFR reduction.

Use of rehabilitation pathways in women with breast cancer in the first 12 months of the disease: a retrospective study.

BACKGROUND: Breast cancer (BC) presents important physical and psychological challenges that should be appropriately addressed through continuous, integrated and individualized rehabilitation programs after treatment. In this study, we aimed to collect more information on the rehabilitation patterns and utilization of healthcare services by women with BC. METHODS: We retrospectively analyzed data from two archives of the Lazio Regional Health System Database to assess rehabilitation patterns in women diagnosed with BC in the Lazio region (Italy) in 2008. RESULTS: A total of 5538 women diagnosed with BC were considered in the present study. Most patients (81.7%) received outpatient rehabilitative care, consisting mainly of pathology-related interventions and, more rarely, disability-related interventions (mainly motor rehabilitation and rarely cognitive or psychological therapy). Few patients followed an inpatient (1.3%) or an intensive outpatient rehabilitation program (1.0%). CONCLUSION: Most patients do not receive adequate rehabilitation care during the first year after diagnosis. More information and better rehabilitation services should be provided to help patients with BC access rehabilitation programs. The study also suggests the importance of psychosocial and cognitive interventions, which is a major unmet need in women with BC.

Analysis of adolescent oncology cases from 2008 through 2018 in a tertiary-level hospital: an opportunity for improvement.

Purpose: The purpose of this study was to disclose the variability of pathways currently taken in the treatment of adolescent patients from diagnosis to final follow-up with a view to developing a more homogenous system. Patients & methods: A cross-sectional, observational and retrospective study of the cancer diagnosis and assignment to medical care teams in adolescent patients (12-20 years) from January 2008 to December 2018 was conducted. A total of 345 adolescent patients aged between 12 and 20 years, diagnosed with cancer and treated at Hospital Clinico Universitario Virgen de la Arrixaca were included. Results: CNS tumors, followed by leukemia were the most frequent tumors. At the time of diagnosis, the highest incidences of patients were assisted in the pediatrics service adult oncology service (21.7%) and hematology (11%). Conclusion: Our aim is to highlight the need for a better transition for patients from pediatric to adult oncology and hematology services.

Lay abstract This study shows the reality of the care of adolescent cancer patients in a hospital in southern Spain. A cross-sectional, observational and retrospective study of cancer diagnoses and assignment to medical care teams in adolescent patients (12­20 years) from January 2008 to December 2018 was conducted. A total of 345 adolescent patients between 12 and 20 years old who had a cancer diagnosis and were treated at Hospital Clinico Universitario Virgen de la Arrixaca were included. CNS tumors, followed by leukemia were the most frequent. At the time of diagnosis, the patients were most commonly attended by the pediatrics service, which concentrates 46.5% of the study population. There is great variability in the treatment and follow-up of the same tumors. The need for a better transition for patients from pediatric to adult oncology and hematology services is demonstrated.

Treatment stage migration and treatment sequences in patients with hepatocellular carcinoma: drawbacks and opportunities.

PURPOSE: This retrospective analysis focuses on treatment stage migration in patients with hepatocellular carcinoma (HCC) to identify successful treatment sequences in a large cohort of real-world patients. METHODS: 1369 HCC patients referred from January 1993 to January 2020 to the tertiary center of the Heidelberg University Hospital, Germany were analyzed for initial and subsequent treatment patterns, and overall survival. RESULTS: The most common initial treatment was transarterial chemoembolization (TACE, n = 455, 39.3%) followed by hepatic resection (n = 303, 26.1%) and systemic therapy (n = 200, 17.3%), whereas the most common 2nd treatment modality was liver transplantation (n = 215, 33.2%) followed by systemic therapy (n = 177, 27.3%) and TACE (n = 85, 13.1%). Kaplan-Meier analysis revealed by far the best prognosis for liver transplantation recipients (median overall survival not reached), followed by patients with hepatic resection (11.1 years). Patients receiving systemic therapy as their first treatment had the shortest median overall survival (1.7 years; P < 0.0001). When three or more treatment sequences preceded liver transplantation, patients had a significant shorter median overall survival (1st seq.: not reached; 2nd seq.: 12.4 years; 3rd seq.: 11.1 years; beyond 3 sequences: 5.5 years; P = 0.01). CONCLUSION: TACE was the most common initial intervention, whereas liver transplantation was the most frequent 2nd treatment. While liver transplantation and hepatic resection were associated with the best median overall survival, the timing of liver transplantation within the treatment sequence strongly affected median survival.

Health service organisation impact on lower extremity amputations in people with type 2 diabetes with foot ulcers: systematic review and meta-analysis.

AIMS: Despite the evidence available on the epidemiology of diabetic foot ulcers and associated complications, it is not clear how specific organizational aspects of health care systems can positively affect their clinical trajectory. We aim to evaluate the impact of organizational aspects of care on lower extremity amputation rates among people with type 2 diabetes affected by foot ulcers. METHODS: We conducted a systematic review of the scientific literature published between 1999 and 2019, using the following key terms as search criteria: people with type 2 diabetes, diagnosed with diabetic foot ulcer, treated with specific processes and care pathways, and LEA as primary outcome. Overall results were reported as pooled odds ratios and 95% confidence intervals obtained using fixed and random effects models. RESULTS: A total of 57 studies were found eligible, highlighting the following arrangements: dedicated teams, care pathways and protocols, multidisciplinary teams, and combined interventions. Among them, seven studies qualified for a meta-analysis. According to the random effects model, interventions including any of the four arrangements were associated with a 29% reduced risk of any type of lower extremity amputation (OR = 0.71; 95% CI 0.52-0.96). The effect was larger when focusing on major LEAs alone, leading to a 48% risk reduction (OR = 0.52; 95% CI 0.30-0.91). CONCLUSIONS: Specific organizational arrangements including multidisciplinary teams and care pathways can prevent half of the amputations in people with diabetes and foot ulcers. Further studies using standardized criteria are needed to investigate the cost-effectiveness to facilitate wider implementation of improved organizational arrangements. Similarly, research should identify specific roadblocks to translating evidence into action. These may be structures and processes at the health system level, e.g. availability of professionals with the right skillset, reimbursement mechanisms, and clear organizational intervention implementation guidelines.

Clinical characteristics and outcomes of patients with venous thromboembolism according to diagnosis on weekends versus on weekdays.

There are uncertainties on the influence of the days of diagnosis in a week (weekends versus weekdays) on clinical outcomes in patients with acute venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis (DVT). The COMMAND VTE registry is a multicenter cohort study enrolling 3027 consecutive patients with acute symptomatic VTE. The current study population consisted of 337 patients diagnosed on weekends and 2690 patients diagnosed on weekdays. We compared the clinical characteristics, management strategies and 30-day outcomes between the 2 groups. The patients diagnosed on weekends more often presented with PE (72% vs. 55%, P < 0.001), and with more severe hemodynamic condition for PE patients. The patients diagnosed on weekends more often received initial parenteral anticoagulation therapy and thrombolysis than those diagnosed on weekdays. The cumulative 30-day incidence of all-cause death was not significantly different between the two groups among PE patients (diagnosis on weekends: 6.2% vs. diagnosis on weekdays: 6.5%, P = 0.87), as well as among DVT patients (0.0% vs. 1.5%, P = 0.24). The most frequent cause of deaths was fatal PE in both groups among PE patients. The risks for recurrent VTE and major bleeding at 30-day were not significantly different between the 2 groups among PE patients, nor among DVT only patients. In conclusion, the VTE patients diagnosed on weekends presented more often with PE, and with more severe condition for PE patients. Nevertheless, the risk for 30-day mortality was not significantly different between patients diagnosed on weekends and on weekdays.

Leveraging the Combined Predictive Value of Ultrasound and Laboratory Data to Reduce Radiation Exposure and Resource Utilization in Children with Suspected Appendicitis.

BACKGROUND: Previous investigation has shown that the combined predictive value of white blood cell count and ultrasound (US) findings to be superior to either alone in children with suspected appendicitis. The purpose of this study was to evaluate the impact of a diagnostic clinical pathway (DCP) leveraging the combined predictive value of these tests on computed tomography (CT) utilization and resource utilization. METHODS: Retrospective cohort study comparing 8 mo of data before DCP implementation to 18 mo of data following implementation. The pathway incorporated decision-support for disposition (operative intervention, observation, or further cross-sectional imaging) based on the combined predictive value of laboratory and US data (stratifying patients into low, moderate, and high-risk groups). Study measures included CT and magnetic resonance imaging utilization, imaging-related cost, time to appendectomy, and negative appendectomy rate. RESULTS: Ninety-seven patients in the preintervention period were compared with 319 patients in the postintervention period. Following DCP implementation, CT utilization decreased by 86% (21% versus 3%, P < 0.001). Mean time to appendectomy decreased from 8.5 to 7.2 h (P < 0.001), and the negative appendectomy rate remained unchanged (5% versus 4%, P = 0.54). Magnetic resonance imaging utilization increased following pathway implementation (1% versus 7%, P = 0.02); however, median imaging-related cost was significantly lower in the postimplementation period ($283/case to $270/case, P = 0.002) CONCLUSIONS: In children with suspected appendicitis, implementation of a DCP leveraging the combined predictive value of white blood cell and US data was associated with a reduction in CT utilization, time to appendectomy, and imaging-related cost.

Dramatic Changes in Oncology Care Pathways During the COVID-19 Pandemic: The French ONCOCARE-COV Study.

The coronavirus disease 2019 (COVID-19) pandemic may have affected cancer management. We aimed to evaluate changes in every oncology care pathway essential step, from screening to treatment, during the pandemic. Monthly oncological activity differences between 2019 and 2020 (screening tests, histopathological analyzes, multidisciplinary tumor board meetings (MTBMs), diagnostic announcement procedures (DAPs), and treatments were calculated in two French areas experiencing different pandemic intensity (Reims and Colmar). COVID-19 has had a dramatic impact in terms of screening (-86% to -100%), diagnosis (-39%), and surgical treatment (-30%). This global decrease in all essential oncology care pathway steps contrasted with the relative stability of chemotherapy (-9%) and radiotherapy use (-16%). Outbreak occurred earlier and with more intensity in Colmar but had a comparable impact in both areas regarding MTMBs and DAPs. The current ONCOCARE-COV study is still in progress and with a longer follow-up to analyze postlockdown situation.

Intravenous thrombolysis in a peripheral primary stroke center without advanced imaging, a retrospective 2016-2017 cohort study.

PURPOSE OF THE STUDY: The hyperacute care of ischemic stroke has evolved markedly. It is unclear to which level stroke centre patients should primarily be taken so information of intravenous thrombolysis (IVT) outcomes in smaller centres are needed. METHODS: All IVT episodes in North Karelia Central hospital in 2016-2017 were analysed retrospectively using hospital registries and individual medical records. RESULTS: IVT had been given to 75 patients (47% women) whose median age was 74 years [IQR 64, 81; no gender difference (p = 0.70)]. Median NIHSS on admission was 6 (IQR 4, 10) and onset-to-treatment time (OTT) 125 min (95% CI 112-138 min). Two intracranial bleeding complications were observed. Clinical status improved following IVT and 53.4% were independent at six months (85% were independent before the stroke). In a multivariate analysis the NIHSS score was the only predictor (B = 0.12, R2=0.34, p = 0.0001) of modified Rankin Scale (mRS). Large-vessel occlusion (LVO) was identified in 27% (35% women). Their median mRS was 2.0 (25% had died). Endovascular thrombectomy had followed IVT in 30% of the LVO-patients. CONCLUSIONS: IVT results were generally in this peripheral PSC-level hospital without advanced imaging capabilities, but LVO outcomes need improvement. A mothership strategy should be evaluated.

Management of Nonoperative Diverticulitis : Is Surgical Admission Always Best?

BACKGROUND: Institutional pathways (IPs) allow efficient utilization of health care resources. Recent literature reports decreased hospital length of stay (LOS), complications, and costs with the admittance of surgical disease to surgical services. Our study aimed to demonstrate that admission to surgery for nonoperative, acute diverticulitis reduces hospital LOS, and cost, with comparable complication rates. METHODS: In January 2017, we defined IPs for diverticulitis, mandating emergency department admission to a surgical service. Patients admitted from October 2015 to June 2016 (pre-protocol, control cohort) were compared with those admitted January 2017-September 2018 (post-protocol, IP cohort). Primary outcomes included hospital LOS, direct cost, indirect cost, total cost, and 30-day readmission. Student's 2-tailed t-test and chi-square analysis were utilized, with statistical significance P < .05. RESULTS: Nonoperative management of acute diverticulitis occurred in 62 (74%) patients in the control cohort. One hundred and eleven patients (85%) were admitted to the IP cohort. Patient characteristics were similar, except for a higher percentage of surgical patients utilizing private insurance and younger in age. Interestingly, no difference in hospital LOS (3.8 vs 4.7 days; P = 0.07), direct cost ($2639.44 vs $3251.52; P = .19), or overall cost ($5968.67 vs $6404.08, P = .61) was found between cohorts. Thirty-day readmission rates were comparable at 8% and 11% (P = .59). CONCLUSION: Institutional policy mandating admissions for patients receiving nonoperative management of diverticulitis to surgical services does not reduce hospital LOS or cost. This argues that admission to medical services may be an acceptable practice. This raises the question, is acute diverticulitis always a surgical issue?

Avaliação da qualidade dos registros de cartões de pré-natal de mulheres urbanas / Evaluación de la calidad de los registros de tarjeta prenatal de mujeres urbanas / Quality assessment of antenatal care home-based records of urban women

Resumo Objetivo Avaliar registros dos cartões de pré-natal de puérperas atendidas em maternidades públicas e privadas. Método Estudo transversal que analisou fotos de 394 cartões de pré-natal de mulheres que participaram da pesquisa Nascer em Belo Horizonte. Os registros foram avaliados quanto ao preenchimento, legibilidade e completude das informações sociodemográficas, clínicas, obstétricas e exames laboratoriais. Resultados Evidenciou-se que 88,5% dos cartões não apresentaram registro do nome da unidade básica de referência, 76,9%, da maternidade de referência e 82,4%, da instituição de realização do pré-natal. A avaliação do edema, o uso de sulfato ferroso e ácido fólico não foram registrados em 55%, 91,1% e 92,6% dos cartões, respectivamente. A ausência de registros no gráfico de peso foi identificada em 86,8% dos cartões, e no de altura uterina, 79,7%. Conclusão e implicações para a prática Existem grandes lacunas no registro do processo de cuidado pré-natal nos cartões e cadernetas, o que pode comprometer a qualidade da assistência e o acompanhamento das gestantes. Os achados apontam para a necessidade da educação permanente em serviço direcionada aos profissionais de saúde, como os enfermeiros, quanto à importância da realização e registro das ações preconizadas no cuidado pré-natal.

Resumen Objetivo Analizar registros de las tarjetas de prenatal de puérperas atendidas en maternidades públicas y privadas. Métodos Estudio transversal, con fotos de 394 tarjetas de prenatal, provenientes de la investigación Nascer em Belo Horizonte (Nacer en Belo Horizonte), que analizó registros en cuanto al llenado, legibilidad y completitud de las informaciones sociodemográficas, clínicas, obstétricas y exámenes de laboratorio. Resultados El 88,5% de las tarjetas no tuvieron registro del nombre de la unidad básica de referencia, el 76,9%, de la maternidad de referencia y el 82,4%, de la institución de realización del prenatal. Evaluación del edema, uso de sulfato ferroso y ácido fólico no se registraron en el 55%, 91,1% y 92,6% de las tarjetas, respectivamente. La ausencia de registros en el gráfico de peso fue identificada en el 86,8% de las tarjetas, y en el 79,7% de altura uterina. Conclusión Existen grandes lagunas en el registro del proceso de asistencia prenatal, pudiendo comprometer la calidad de la asistencia y el acompañamiento de las gestantes. Implicaciones para la práctica Se necesita educación permanente dirigida a profesionales de la salud, como enfermeras, sobre la importancia de llevar a cabo y registrar las acciones recomendadas en la atención prenatal.

Abstract Objective To evaluate the antenatal care (ANC) home-based records of puerperal women attended in public and private maternity hospitals. Methods Cross-sectional study that analyzed photographs of 394 ANC home-based records of women who participated in the research Nascer em Belo Horizonte (Born in Belo Horizonte, in free translation). Records were assessed regarding completeness, legibility and completeness of sociodemographic, clinical, obstetric and laboratory data. Results 88.5% of the cards had no record of the name of the primary care unit of reference, 76.9% of the maternity of reference and 82.4% of the ANC institution. Evaluation of edema, use of ferrous sulfate and folic acid were not registered in 55%, 91.1% and 92.6% of the cards, respectively. The absence of records in the weight chart was identified in 86.8% of the cards, and in the uterine height chart, 79.7%. Conclusions and implications for practice There are large gaps in the registration of the ANC process in the home-based records, which may compromise the quality of care and follow-up of pregnant women. The findings point to the need for permanent education in service directed to health professionals, such as nurses, regarding the importance of carrying out and registering the actions recommended in ANC.

Shaping a data-driven era in dementia care pathway through computational neurology approaches.

BACKGROUND: Dementia is caused by a variety of neurodegenerative diseases and is associated with a decline in memory and other cognitive abilities, while inflicting an enormous socioeconomic burden. The complexity of dementia and its associated comorbidities presents immense challenges for dementia research and care, particularly in clinical decision-making. MAIN BODY: Despite the lack of disease-modifying therapies, there is an increasing and urgent need to make timely and accurate clinical decisions in dementia diagnosis and prognosis to allow appropriate care and treatment. However, the dementia care pathway is currently suboptimal. We propose that through computational approaches, understanding of dementia aetiology could be improved, and dementia assessments could be more standardised, objective and efficient. In particular, we suggest that these will involve appropriate data infrastructure, the use of data-driven computational neurology approaches and the development of practical clinical decision support systems. We also discuss the technical, structural, economic, political and policy-making challenges that accompany such implementations. CONCLUSION: The data-driven era for dementia research has arrived with the potential to transform the healthcare system, creating a more efficient, transparent and personalised service for dementia.

Implementation of a clinical nursing pathway for percutaneous coronary intervention: A randomized controlled trial protocol.

BACKGROUND: Acute myocardial infarction is a very common disease in the emergency room. Emergency percutaneous coronary intervention (PCI) is the first choice to open infarct-related artery in time to regain the active blood flow of myocardial tissue. Clinical nursing pathway (CNP), namely clinical project, is an original nursing mode with good quality, outstanding efficiency, and low treatment spending, so it has attracted more and more attention. However, few studies have reported the implementation of a CNP in PCIs. The purpose of the protocol is to assess the impact of CNP on the clinical efficacy of transradial emergency PCI. METHODS: This is a randomized controlled, single center trial which will be implemented from January 2021 to June 2021. Hundred samples diagnosed with acute myocardial infarction will be included in this study. It was authorized via the Ethics Committee of Changshan County People's Hospital (CCPH002348). Patients are assigned to the following groups: control group, given normal routine care; CNP group, treated with CNP plan. The time from door to balloon, hospitalization expenses, length of stay, postoperative complications, patients' satisfaction with treatment are compared and analyzed. All data are collected and analyzed by Social Sciences software version 21.0 (SPSS, Inc., Chicago, IL) program. RESULTS: Differences of clinical outcomes between groups (). CONCLUSION: This original evidence-based nursing model can be used as the foundation for further research. TRIAL REGISTRATION NUMBER: researchregistry6030.

A quality improvement project for managing hypocalcemia after pediatric total thyroidectomy.

Objectives Hypocalcemia following total thyroidectomy (TT) is relatively common. It may result in significant morbidity, prolonged hospital stay, and increased costs. Treatment with intravenous (IV) calcium gluconate may also carry significant risks. In pediatrics, management consensus guidelines are lacking. Methods At Phoenix Children's Hospital, a team of pediatric endocrinologists, surgeons and otolaryngologists developed a clinical pathway for patients undergoing TT. It was a Quality Improvement (QI) project with the primary aim of decreasing IV calcium gluconate use from a baseline of 68% to less than 40% over 15 months. Secondary aims included reducing hypocalcemia and length of hospitalization. Interventions included sending weekly pathway reminder emails, starting pre-operative calcium, and pathway implementation into the electronic health record. Results Twenty-seven patients underwent TT over 15 months. IV calcium gluconate use dropped to 48%. Hypocalcemia and length of hospitalization were 96% and 52.7 h (range 21.1-115.7) respectively. Pathway adherence improved after targeted interventions. Eleven (73%) of the 15 patients whose post-operative parathyroid hormone (PTH) nadir was below 15 pg/mL required IV calcium gluconate vs. two (17%) out of 12 with levels above this threshold. Conclusions Standardizing care allowed for objective outcome analysis. We learned that post-operative serum PTH level was the main risk factor for requiring IV calcium gluconate. Implementing the pathway as a QI project allows for revisions based on outcomes, ultimately resulting in a pathway that best utilizes our infrastructure to optimize care. Other pediatric institutions may face similar challenges and can potentially learn from our experience.

Impact of a Streamlined Trauma-Focused Smartphone Application on Protocol Compliance and Delivery of Care.

BACKGROUND: In November 2015, an institution-specific mobile application (app) was created to provide rapid access to trauma protocols. The app was tested, and the results suggested that the app was difficult to use as it linked to web-based databases. In June 2018, the app was redesigned with protocol infographics and algorithms that are available offline, eliminating the need to scroll through web pages. We tested the redesigned app's ability to provide information quickly, in a user-friendly manner. METHODS: This was a prospective, experimental analysis of a streamlined, institution-specific trauma app. Participants included general surgery residents, advanced practice providers, and attending trauma surgeons. The primary outcomes of measure were time to complete an exam with trauma scenarios and the number of questions answered correctly. The primary exposure of interest was access to the app during the exam. RESULTS: There were 35 study participants: 17 with the 2018 version of the app to complete the quiz and 18 without app access. The group with access scored higher than those without access (70% versus 50%, P = 0.0005) as well as those with the old version of the app in the 2015 study (70% versus 55%, P = 0.0250). App access eliminated a significant difference in exam scores between residents and attendings that was present without the app. CONCLUSIONS: A mobile app with offline access to protocol infographics and algorithms gives providers access to recommended practices and may improve delivery of trauma care. The app is helpful to residents and helps bridge the knowledge gap between groups when the app is not available. LEVEL OF EVIDENCE: Level III.