Resultados de una encuesta nacional sobre el manejo de los pacientes diagnosticados de diverticulitis aguda no complicada / Results of a national survey about the management of patients with acute uncomplicated diverticulitis

Introducción: El manejo de los pacientes diagnosticados de diverticulitis aguda no complicada ha evolucionado en los últimos años, y según diversas guías clínicas internacionales actuales, el tratamiento ambulatorio y sin antibioterapia puede ser utilizado en pacientes seleccionados. El objetivo de este estudio es evaluar la adhesión de los distintos centros nacionales a estas y otras recomendaciones en esta enfermedad. Métodos: Se realizó una encuesta online a nivel nacional que se dio a conocer a través de diversas aplicaciones informáticas y se analizaron estadísticamente los resultados obtenidos. Resultados: Participaron 104 cirujanos, representando 69 centros hospitalarios nacionales. En el 82,6% de los centros, se realiza manejo ambulatorio de los pacientes diagnosticados de diverticulitis aguda no complicada. El 23,2% de los centros tiene implantado un protocolo de tratamiento sin antibioterapia en pacientes seleccionados, mientras que en los centros que no siguen estas recomendaciones, las razones principales son las dificultades logísticas para su desarrollo (49,3%) y la ausencia de evidencia actual para ello (44,8%). Se han encontrado diferencias estadísticamente significativas al comparar la implantación de dichos protocolos entre centros con unidades acreditadas avanzadas y aquellas que no, con mayores tasas de manejo ambulatorio y sin antibioterapia en los centros acreditados avanzados (p≤0,05). Conclusiones: A pesar de ser una enfermedad muy frecuente, existe mucha heterogeneidad en su tratamiento a nivel nacional, por lo que sería recomendable la unificación de criterios diagnósticos y de tratamiento mediante la colaboración de las sociedades científicas y la simplificación de la puesta en marcha de protocolos hospitalarios.(AU)

Introduction: Management of patients diagnosed of acute uncomplicated diverticulitis has evolved lately and according to the latest guidelines, outpatient treatment and management without antibiotherapy may be used in selected patients. The aim of this study is to evaluate the adhesion among national centres to these and others recommendations related to this pathology. Methods: An online national survey, that has been broadcast by several applications, was performed. The results obtained were statistically analysed. Results: A total of 104 surgeons participated, representing 69 national hospitals. Of those, in 82.6% of the centers, outpatient management is performed for acute uncomplicated diverticulitis. 23.2% of the hospitals have a protocol stablished for treatment without antibiotherapy in selected patients. Centers that do not follow these protocols allege that the mean reasons are the logistic difficulties to set them up (49.3%) and the lack of current evidence for it (44.8%). Significative statistical differences have been found when comparing the establishment of such protocols between centers with advanced accredited units and those who are not, with higher rates of outpatient management and treatment without antibiotics in accredited units (P≤.05). Conclusions: In spite that this a very common disease, there is a huge national heterogeneity in its treatment. This is why it would adviseable to unify diagnostic and treatment criteria by the collaboration of scientific societies and the simplification of the development of hospitalary protocols.(AU)

Results of a national survey about the management of patients with acute uncomplicated diverticulitis.

INTRODUCTION: Management of patients diagnosed of acute uncomplicated diverticulitis has evolved lately and according to the latest guidelines, outpatient treatment and management without antibiotherapy may be used in selected patients. The aim of this study is to evaluate the adhesión among national centres to these and others recommendations related to this pathology. METHODS: An online national survey, that has been broadcast by several applications, was performed. The results obtained were statistically analysed. RESULTS: A total of 104 surgeons participated, representing 69 national hospitals. Of those, in 82.6% of the centres, outpatient management is performed for acute uncomplicated diverticulitis. 23.2% of the hospitals have a protocol stablished for treatment without antibiotherapy in selected patients. Centres that do not follow these protocols allege that the mean reasons are the logistic difficulties to set them up (49.3%) and the lack of current evidence for it (44.8%). Significative statistical differences have been found when comparing the establishment of such protocols between centres with advanced accredited units and those who are not, with higher rates of outpatient management and treatment without antibiotics in accredited units (p ≤ .05). CONCLUSIONS: In spite that this a very common disease, there is a huge national heterogeneity in its treatment. This is why it would adviseable to unify diagnostic and treatment criteria by the collaboration of scientific societies and the simplification of the development of hospitalary protocols.

Nurse and Social Worker Palliative Telecare Team and Quality of Life in Patients With COPD, Heart Failure, or Interstitial Lung Disease: The ADAPT Randomized Clinical Trial.

Importance: Many patients with chronic obstructive pulmonary disease (COPD), heart failure (HF), and interstitial lung disease (ILD) endure poor quality of life despite conventional therapy. Palliative care approaches may benefit this population prior to end of life. Objective: Determine the effect of a nurse and social worker palliative telecare team on quality of life in outpatients with COPD, HF, or ILD compared with usual care. Design, Setting, and Participants: Single-blind, 2-group, multisite randomized clinical trial with accrual between October 27, 2016, and April 2, 2020, in 2 Veterans Administration health care systems (Colorado and Washington), and including community-based outpatient clinics. Outpatients with COPD, HF, or ILD at high risk of hospitalization or death who reported poor quality of life participated. Intervention: The intervention involved 6 phone calls with a nurse to help with symptom management and 6 phone calls with a social worker to provide psychosocial care. The nurse and social worker met weekly with a study primary care and palliative care physician and as needed, a pulmonologist, and cardiologist. Usual care included an educational handout developed for the study that outlined self-care for COPD, ILD, or HF. Patients in both groups received care at the discretion of their clinicians, which could include care from nurses and social workers, and specialists in cardiology, pulmonology, palliative care, and mental health. Main Outcomes and Measures: The primary outcome was difference in change in quality of life from baseline to 6 months between the intervention and usual care groups (FACT-G score range, 0-100, with higher scores indicating better quality of life, clinically meaningful change ≥4 points). Secondary quality-of-life outcomes at 6 months included disease-specific health status (Clinical COPD Questionnaire; Kansas City Cardiomyopathy Questionnaire-12), depression (Patient Health Questionnaire-8) and anxiety (Generalized Anxiety Disorder-7) symptoms. Results: Among 306 randomized patients (mean [SD] age, 68.9 [7.7] years; 276 male [90.2%], 30 female [9.8%]; 245 White [80.1%]), 177 (57.8%) had COPD, 67 (21.9%) HF, 49 (16%) both COPD and HF, and 13 (4.2%) ILD. Baseline FACT-G scores were similar (intervention, 52.9; usual care, 52.7). FACT-G completion was 76% (intervention, 117 of 154; usual care, 116 of 152) at 6 months for both groups. Mean (SD) length of intervention was 115.1 (33.4) days and included a mean of 10.4 (3.3) intervention calls per patient. In the intervention group, 112 of 154 (73%) patients received the intervention as randomized. At 6 months, mean FACT-G score improved 6.0 points in the intervention group and 1.4 points in the usual care group (difference, 4.6 points [95% CI, 1.8-7.4]; P = .001; standardized mean difference, 0.41). The intervention also improved COPD health status (standardized mean difference, 0.44; P = .04), HF health status (standardized mean difference, 0.41; P = .01), depression (standardized mean difference, -0.50; P < .001), and anxiety (standardized mean difference, -0.51; P < .001) at 6 months. Conclusions and Relevance: For adults with COPD, HF, or ILD who were at high risk of death and had poor quality of life, a nurse and social worker palliative telecare team produced clinically meaningful improvements in quality of life at 6 months compared with usual care. Trial Registration: ClinicalTrials.gov Identifier: NCT02713347.

Acceptability of Specialist Psychotherapy with Emotion for Anorexia in Kent and Sussex (SPEAKS): A novel intervention for anorexia nervosa.

OBJECTIVE: Investigate the acceptability of Specialist Psychotherapy with Emotion for Anorexia in Kent and Sussex (SPEAKS), a novel intervention for anorexia nervosa (AN), conducted as a feasibility trial to provide an initial test of the intervention. METHODS: SPEAKS therapy lasting 9-12 months was provided to 34 people with AN or atypical AN by eight specialist eating disorder therapists trained in the model across two NHS Trusts in the UK (Kent and Sussex) during a feasibility trial. All participants were offered a post-therapy interview; sixteen patients and six therapists agreed. All patient participants were adult females. Interviews were semi-structured and asked questions around individuals' experience of SPEAKS, the acceptability of the intervention and of the research methods. Interviews were analyzed using thematic analysis. RESULTS: Key areas explored in line with research questions led to 5 overarching themes and 14 subthemes: (1) shift in treatment focus and experience, (2) balancing resources and treatment outcomes, (3) navigating the online treatment environment, (4) therapist adaptation and professional development, and (5) research processes. DISCUSSION: SPEAKS was found to be an acceptable intervention for treating AN from the perspective of patients and therapists. The findings provide strong support for delivery of a larger scale randomized control trial. Recommendations for future improvements, particularly pertaining to therapist understanding of the treatment model are detailed, alongside broader clinical implications. PUBLIC SIGNIFICANCE: We aimed to evaluate the acceptability of a new anorexia nervosa treatment called SPEAKS. Interviews were conducted with patients and therapists involved in the pilot study and responses were analyzed. Results showed that both patients and therapists found SPEAKS to be an acceptable treatment for anorexia nervosa. The study suggests that SPEAKS meets the criteria for moving forward with a larger trial to assess its effectiveness.

Transition of care interventions to manage severe COVID-19 in the ambulatory setting: a systematic review.

BACKGROUND: Severe COVID-19, with the need in supplemental oxygen and hospitalization, leads to major burden on patients and healthcare systems. As a result, safe and effective ambulatory treatment strategies for severe COVID-19 are of urgent need. In this systematic review, we aimed to evaluate interventions to transition care to the ambulatory setting for patients with active severe COVID-19 that required supplemental oxygen. METHODS: We searched Medline, Scopus, Web of Science, and DOAJ databases to identify articles with original data published until the 1st of April 2023. Characteristics and outcomes of interventions to transition care to home management were reviewed. Given the heterogeneous settings and outcomes studied, a meta-analysis was not performed. RESULTS: Of the 235 studies identified, 11 observational studies, with 2645 patients, were included. The interventions were initiated from the emergency department, observation units or inpatient units, and included continuous home telemonitoring (n = 8), mobile applications (n = 2), and patient-initiated medical contact (n = 3). Included patients had an overall short length of hospital stay, high readmission rates, and positive patients' feedback. There was a lack of prospective controlled data and cost-effectiveness analyses. CONCLUSION: Our findings highlight the potential in treating severe COVID-19 at the ambulatory setting and the lack of high-quality data in this field. Dedicated medical teams, adjusted monitoring methods, improving clinical trajectory, and correct inclusion settings are needed for safe and effective transition of care.

Mayor uso de teleconsultas programadas y mensajería asincrónica del portal en atención primaria / Increased Use of Scheduled Teleconsultations and Asynchronous Portal Messaging in Primary Care

Introducción: durante la pandemia de COVID-19 hubo un auge sin precedentes de la telemedicina, probablemente por la forzada adopción de tecnología ante las medidas restrictivas. El presente estudio se propuso comparar la interacción y la comunicación entre médicos de cabecera (MC) y pacientes, antes y durante el período de pandemia, en términos de consultas ambulatorias programadas y mensajes del Portal de Salud. Materiales y métodos: corte transversal con muestreo consecutivo de turnos programados y mensajes, ocurridos entre las semanas epidemiológicas (SE) 10 y 23, de 2019 y 2020, respectivamente. Se incluyeron 147 médicos del Servicio de Medicina Familiar y Comunitaria, y una cápita de 73 427 pacientes afiliados al Plan de Salud del Hospital Italiano de Buenos Aires. Se realizó análisis cuantitativo y cualitativo. Resultados: hubo una reducción del 70% de las consultas presenciales (de 76 375 en 2019 a 23 200 en 2020) y un aumento concomitante de teleconsultas (de 255 en la SE13 a 1089 en la SE23). En simultáneo, los mensajes aumentaron sustancialmente (de 28 601 en 2019 a 84 916 en 2020), con un inicio abrupto al comienzo del confinamiento, y una tendencia decreciente a lo largo del tiempo. Antes de la pandemia, el contenido estuvo relacionado con órdenes electrónicas de estudios complementarios, control de resultados, recetas de medicación crónica y/o interconsultas a especialistas, mientras que los dominios más frecuentes durante la pandemia fueron necesidades informativas epidemiológicas, como medidas preventivas para COVID-19, vacuna antineumocócica, vacuna antigripal, casos o sospechas, resultados de hisopados, entre otras. Conclusión: el auge de las tecnologías de la comunicación e información durante la pandemia permitió dar continuidad a los procesos asistenciales en salud pese al distanciamiento físico. Hubo mayor utilización de mensajería por necesidades informativas de los pacientes, y la relación médico-paciente se ha modificado. (AU)

Introduction: during the COVID-19 pandemic, there was an unprecedented boom in telemedicine, probably due to the forced adoption of technology in the face of restrictive measures. This study aimed to compare the interaction and communication between general practitioners and patients before and during the pandemic based on scheduled outpatient consultations and Health Portal messages. Materials and methods: Cross-sectional study with a consecutive sampling of scheduled appointments and messages, occurring between epidemiological weeks (EW) 10 and 23 of 2019 and 2020, respectively. We included 147 physicians from the Family and Community Medicine Service and a capita of 73427 patients affiliated with the Hospital Italiano de Buenos Aires health plan. We conducted a quantitative and qualitative analysis. Results: there was a 70% reduction in face-to-face consultations (from 76375 in 2019 to 23200 in 2020) and a concomitant increase in teleconsultations (from 255 in EW13 to 1089 in EW23). Concurrently, messages increased substantially (from 28601 in 2019 to 84916 in 2020), with an abrupt onset at the beginning of confinement and a decreasing trend over time. Before the pandemic, the content involved electronic orders for complementary studies, outcome monitoring, chronic medication prescriptions, or expert consultations. The most frequent domains during the pandemic were epidemiological information needs, such as preventive measures for COVID-19, pneumococcal vaccine, influenza vaccine, cases or suspicions, and swab results, among others. Conclusion: the rise of communication and information technologies during the pandemic allowed the continuity of healthcare processes despite the physical distance. There was increased use of messaging for patients' information needs, and the doctor-patient relationship has changed. (AU)

Quality indicators and outcomes in ambulatory surgery.

PURPOSE OF REVIEW: Quality indicators are used to monitor the quality and safety of care in ambulatory surgery, a specialty in which major morbidity and mortality remain low. As the demand for safe and cost-effective ambulatory surgical care continues to increase, quality indicators and metrics are becoming critical tools used to provide optimal care for these patients. RECENT FINDINGS: Quality indicators are tools used by both regulatory agencies and surgical centers to improve safety and quality of ambulatory surgical and anesthetic care. These metrics are also being used to develop value-based payment models that focus on efficient, safe, and effective patient care. Patient reported outcome measures are a growing method of collecting data on the satisfaction and postoperative recovery period for ambulatory surgical patients. Monitoring of perioperative efficiency and utilization using quality metrics are important to the financial health of ambulatory surgical centers. SUMMARY: Quality indicators will continue to play a growing role in the monitoring of quality and safety in ambulatory surgery, especially with the trend towards value-based reimbursement models and efficient, cost-effective surgical care. Additionally, quality indicators are useful tools to monitor postoperative patient outcomes and recovery pathways and the efficiency of operating room utilization and scheduling.

Management of Acetaminophen Poisoning in the US and Canada: A Consensus Statement.

Importance: The US and Canada currently have no formal published nationwide guidelines for specialists in poison information or emergency departments for the management of acetaminophen poisoning, resulting in significant variability in management. Objective: To develop consensus guidelines for the management of acetaminophen poisoning in the US and Canada. Evidence Review: Four clinical toxicology societies (America's Poison Centers, American Academy of Clinical Toxicology, American College of Medical Toxicology, and Canadian Association of Poison Control Centers) selected participants (n = 21). Led by a nonvoting chairperson using a modified Delphi method, the panel created a decision framework and determined the appropriate clinical management of a patient with acetaminophen poisoning. Unique to this effort was the collection of guidelines from most poison centers in addition to systematic collection and review of the medical literature. Comments from review by external organizations were incorporated before the guideline was finalized. The project began in March 2021 and ended in March 2023. Findings: The search retrieved 84 guidelines and 278 publications. The panel developed guidelines for emergency department management of single or repeated ingestion of acetaminophen. In addition, the panel addressed extended-release formulation, high-risk ingestion, coingestion of anticholinergics or opioids, age younger than 6 years, pregnancy, weight greater than 100 kg, and intravenous acetaminophen use. Differences from current US practice include defining acute ingestion as an ingestion presentation from 4 to 24 hours after overdose was initiated. A revised form of the Rumack-Matthew nomogram was developed. The term massive ingestion was replaced with the term high-risk ingestion and denoted by a specific nomogram line. Other recommendations include specific criteria for emergency department triage, laboratory evaluation and monitoring parameters, defining the role of gastrointestinal decontamination, detailed management of acetylcysteine treatment, associated adverse effects, and stopping criteria for acetylcysteine treatment, as well as criteria for consultation with a clinical toxicologist. Finally, specific treatment considerations, including acetylcysteine dosing, fomepizole administration, and considerations for extracorporeal elimination and transplant evaluation, were addressed. Conclusions and Relevance: This qualitative study provides a consensus statement on consistent evidence-based recommendations for medical, pharmacy, and nursing education and practice to optimize care of patients with acetaminophen poisoning.

Economic burden of skin and skin structure infections due to Gram-positive bacteria in patients on hospital at home-based outpatient parenteral antibiotic therapy (OPAT).

OBJECTIVE: To describe and quantify resource use and direct health costs associated with skin and skin structure infections (SSSIs) caused by Gram-positive bacteria in adults receiving outpatient parenteral antimicrobial therapy (OPAT), administered by Hospital at Home units (HaH) in Spain. METHODS: Observational, multicenter, retrospective study. We included patients of both sexes included in the HaH-based OPAT Registry during 2011 to 2017 who were hospitalized due to SSSIs caused by Gram-positive bacteria. Resource use included home visits (nurses and physician), emergency room visits, conventional hospitalization stay, HaH stay and antibiotic treatment. Costs were quantified by multiplying the natural units of the resources by the corresponding unit cost. All costs were updated to 2019 euros. RESULTS: We included 194 episodes in 189 patients from 24 Spanish hospitals. The most frequent main diagnoses were cellulitis (26.8%) and surgical wound infection (24.2%), and 94% of episodes resulted in clinical improvement or cure after treatment. The median HaH stay was 13 days (interquartile range [IR]:8-22.7), and the conventional hospitalization stay was 5 days (IR: 1-10.7). The mean total cost attributable to the complete infectious process was €7,326 (95% confidence interval: €6,316-€8,416). CONCLUSIONS: Our results suggest that OPAT administered by HaH is a safe and efficient alternative for the management of these infections and could lead to lower costs compared with hospital admission.

[The challenge of assessing a patient's nutritional status and its evolution during treatment. From critical patients to outpatients (II)]. / El reto de evaluar la situación nutricional de los pacientes y su evolución durante el tratamiento. Desde el paciente crítico hasta el paciente ambulatorio (II).

Introduction: The challenge of assessing a patient's nutritional status and its evolution during treatment. From critical patients to outpatients (II).

Introducción: El reto de evaluar la situación nutricional de los pacientes y su evolución durante el tratamiento. Desde el paciente crítico hasta el paciente ambulatorio (II).

Learning in Tension: A Case Study Examining What Internal Medicine Residents Learn in the Ambulatory Care Setting.

Introduction: Medical care of patients with complex conditions has shifted to the ambulatory setting, whereas current knowledge of resident learning is primarily based on studies from inpatient settings. Preparing trainees to adapt to this shift necessitates an understanding of what internal medicine (IM) residents currently learn during ambulatory rotations. The aim of this study is to identify what residents learn during their ambulatory care experience. Methods: Using a qualitative instrumental case study design, the authors conducted separate focus groups with IM trainees (n = 15), supervisors (n = 16), and program directors (n = 5) from two IM programs in New York City, USA in 2019. Participants were invited via email, and focus group sessions were complemented by document analysis of ambulatory syllabi. Results: Based on focus group commentary and document analysis, content learned in the ambulatory setting encompassed three domains; 1) patient needs, 2) the resident's role within a healthcare team, and 3) health system opportunities and limitations. Residents also learned about tensions within and between these domains including the skills needed to care for patients versus the skills acquired, a desire for ownership of patient care versus fragmented care, and time allotted versus time required. Discussion: This study revealed two outcomes about what residents learn during their ambulatory care experience. First, learning content largely fell into three domains. Second, residents learned about the tensions between ideal care delivery and the realities of practice. These results highlight the imperative to better align curricula with clinical environments to meet the learning needs of residents.

Medical Outcomes of Acute Aspirin Single Substance Poisoning in Pediatric Patients.

BACKGROUND: A consensus guideline on salicylate poisoning recommends referring patients to the emergency department if they ingested 150 mg/kg of aspirin. The dose of aspirin associated with severe poisoning in pediatric patients has not been investigated. OBJECTIVE: This study aims to associate medical outcomes with aspirin overdoses in patients 5 years old and younger. METHODS: A retrospective review of data on pediatric patients with single substance aspirin exposures reported from poison centers across the country was conducted. The primary endpoint was to associate aspirin doses with medical outcomes. Secondary endpoints included evaluation of the signs, symptoms, and treatments of ingestion and their association with medical outcomes. RESULTS: There were 26 488 included exposures with aspirin exposures resulting in no effect (92.5%), minor effect (6.0%), moderate effect (1.4%), major effect (0.2%), and death (0.02%). There were 8921 cases with available weight-based dosing information. Median doses associated with no effect, minor effects, moderate effects, major effects, and death ranged between 28.4 and 40.9 mg/kg, 52.5 and 82.3 mg/kg, 132.1 and 182.3 mg/kg, 132.3 and 172.8 mg/kg, and 142.2 and 284.4 mg/kg, respectively. Minor effect and moderate effect exposures were more likely to have alkalinization documented compared to no effect exposures (odds ratio [OR] = 1.75, 95% confidence interval [CI] = 1.41-2.17; OR = 1.79, 95% CI = 1.12-2.86). There was no difference in rates of alkalinization between minor and moderate exposures (OR = 1.02, 95% CI: 0.61-1.7). CONCLUSIONS AND RELEVANCE: Reevaluation of the current recommendation of 150 mg/kg for referral to a healthcare facility is necessary for pediatric acute salicylate overdoses.

Optimization of Medication Point-Of-Prescribing Alerts at a Multi-Site, Ambulatory Care Organization to Aid Clinical Care and Reduce HealthCare Cost.

BackgroundLiterature has shown the integration of electronic alerts into patient care has the potential to improve clinicians' workflow by saving time, increasing efficiency, and improving patient safety. However, despite these possible benefits of alerts, studies have shown that alerts are often overridden by clinicians. Objective: The purpose of this study was to optimize the acceptance rates of medication point-of-prescribing alerts within the electronic medical record (EMR) of an ambulatory care organization. Methods: The study design evaluated the actions taken by clinicians when they were presented with medication point-of-prescribing alerts. These alerts were created by the clinical pharmacy informatics team to help promote cost-effective and safe prescribing. Alerts determined to be high value alerts were optimized to increase clinicians' likelihood of accepting each alert's recommended alternative. The primary objective was to increase acceptance rates of high value alerts. The exploratory objective was to identify the estimated annualized cost-savings when high value alerts were accepted, and a lower cost alternative prescription resulted. Results: The acceptance rate of the optimized point-of-prescribing alerts increased to 8.7%, compared to a 3.2% acceptance in the pre-modification period (P <.001). The lower cost alternative prescriptions that resulted from the accepted alerts translated into an estimated annualized cost-savings of over 2 million dollars. Conclusion: The use of point-of-prescribing alerts with optimized information and specific cost comparisons in an ambulatory setting led to an increase in the acceptance rates of the alerts and more cost-conscious prescribing.

Widening the net: a literature review of antimicrobial agents with potential suitability for outpatient parenteral antimicrobial therapy services-the importance of storage and stability.

OBJECTIVES: Outpatient parenteral antimicrobial therapy (OPAT) services using continuous infusions (CIs) of antimicrobial agents in elastomeric devices require evidence of acceptable stability of the agent over the infusion period. A period of refrigerated storage of filled devices, followed by the CI period, is useful for OPAT services but can present a significant challenge to the stability of drugs. The aims of this study were to review fresh-filled stability data on antimicrobials which would be useful for OPAT services and to identify suitable candidates for further assessment. METHODS: Searches identified papers relating to stability assessments of antimicrobials for immediate use tested above 31°C using a stability-indicating method. RESULTS: We identified 18 stability studies published in 12 papers between 2015 and 2020, assessing the stability of 10 agents. Aminopenicillins like ampicillin and amoxicillin appear too unstable for CI, while benzylpenicillin may benefit from buffering to improve its stability. Cephalosporins vary in their stability and CI periods of 24 hours may not be achievable. Of the carbapenems, there are insufficient data for doripenem but meropenem has been extensively studied and is unsuitable for CI longer than 6 hours. Voriconazole may be suitable for CI but needs further investigation. CONCLUSIONS: Some drugs identified in our review are unlikely to be suitable for continuous infusion in OPAT services due to instability. Using a 'fresh-fill' approach, without refrigerated storage, may make some drugs useful while other agents should be considered for further assessment to Yellow Cover Document standards. The impact of buffering for penicillins should be assessed further.

Perioperative Telemedicine Utilization Among Geriatric Patients Being Evaluated for Abdominal Wall Reconstruction and Hernia Repair.

Introduction: Perioperative telemedicine services have increasingly been utilized for ambulatory care, although concerns exist regarding the feasibility of virtual consultations for older patients. We sought to review telemedicine encounters for geriatric patients evaluated at a hernia repair and abdominal wall reconstruction center. Methods: A retrospective review of telemedicine encounters between May 2020 and May 2021 was performed. Patient characteristics and encounter-specific outcomes were compared among geriatric (older than65 years old) and nongeriatric patients. Clinical care plans for encounters were reviewed to determine potential downstream care utilization. Patient-derived benefits related to time saved in travel time was calculated using geo-mapping. Outcomes for postoperative encounters were assessed to determine if complication rates differed between geriatric and nongeriatric populations. Results: A total of 313 telemedicine encounters (geriatric: 41.9%) were conducted among 251 patients. Reviewing preoperative factors for hernia care, geriatric patients presented with higher rates of recurrent or incisional hernias (87.9% vs. 70.7%, p < 0.01). Potential travel time was longer for geriatric patients (104 min vs. 42 min, p = 0.03) in the preoperative setting. No differences in clinical care plans were found. Only 8.6% of preoperative encounters resulted in recommendations for supplemental in-person evaluation. Operative plans were coordinated for 42.5% of all preoperative telemedicine encounters. There was no difference in complication rate between geriatric and nongeriatric patients (p > 0.05) in the postoperative setting, with no complications directly attributable to telemedicine-based care. Conclusions: Telemedicine-based evaluations appear to function well among geriatric patients seeking hernia repair and abdominal wall reconstruction. Clinical care plans rendered following telemedicine-based encounters are appropriate with a low rate of supplemental in-person evaluations. Telemedicine use resulted in significantly more time saved in commuting to and from clinic for geriatric patients.

Impact of an outpatient parenteral antimicrobial treatment (OPAT) as part of a paediatric-specific PROA program.

INTRODUCTION: Outpatient parenteral antimicrobial treatment (OPAT) is an alternative to in-patient care in carefully selected patients. This study presents a self-administration OPAT program integrated within the pediatric antibiotic stewardship program (ASP) in a pediatric tertiary care center. MATERIAL AND METHODS: Descriptive, retrospective and unicentric study. Data from all patients under 20 years of age who were prescribed treatment by a pediatric unit during 2019 and 2020 were included. Data regarding number of saved beds and estimating the opportunity cost of the OPAT program for the hospital were analyzed. RESULTS: Fifty-seven patients received 106 episodes of treatment. Favorable clinical outcome occurred in 74.5% of the episodes. The main cause of premature interruption was unfavorable clinical outcome of the infection (37.1%). A total of 2.62 beds/day were saved, resulting in an economic benefit of 1,069,963 €. CONCLUSION: A self-administration OPAT program integrated within the pediatric ASP has proven to be safe and effective and provides economic benefits.

Assessing appropriate panel size and optimization of quality metrics for ambulatory care pharmacists in the primary care setting.

PURPOSE: Chronic disease state management utilizing pharmacists improves quality metrics, allows providers to focus on acute issues, and decreases physician burnout risk. Minimal data exist on pharmacist panel size and its impact. This study aimed to determine appropriate pharmacist panel size based on workload, quality metrics, and patient access. METHODS: This study was a retrospective, multiclinic cohort analysis of patients with diabetes managed by pharmacists at 7 outpatient clinics. The primary objective calculated panel size per full-time equivalent (FTE) utilizing the National Health Interview Survey. Secondary objectives calculated the ideal FTE based on provider to pharmacist ratio and determined the impact of pharmacist panel size on patient access and quality metrics. RESULTS: A total of 4,399 patients were analyzed from 2017 through 2019, with age (range, 57.4 to 62.6 years), sex (52.5% to 63.5% female), race (41.2% to 93.7% African American), insurance type (13.3% to 41% Medicaid), and mean number of medications (13.1 to 20.3) significantly different between sites. Primary outcome results showed that actual panel sizes were less than calculated. However, secondary outcomes indicated that each site was understaffed (actual 0.2 to 0.5 FTE vs calculated 2.52 to 7.34 FTEs) and overbooked (95% to 122% capacity, 17 to 54.2 days for time to third next available appointment). Patients met the composite quality metric 35.1% to 56.3% of the time across sites. CONCLUSION: This study supports the use of patient access data to determine appropriate pharmacist panel size. Utilizing provider panel size to pharmacist ratio and time to third next available appointment is preferable for determining appropriate pharmacist panel size. Further research is needed to evaluate return times to help determine an ideal pharmacist panel size.

Safety, effectiveness, women's experience, and economic costs of outpatient induction in women with uncomplicated pregnancies: A systematic review and meta-analyses.

BACKGROUND: Induction of labor is increasing worldwide, and some countries have started to introduce outpatient induction in low-risk women. OBJECTIVES: To assess current knowledge concerning the safety, efficacy, women's experience, and economic costs of outpatient induction compared with inpatient induction. SEARCH STRATEGY: Multiple databases were last searched on October 19, 2021. Studies were selected according to our pre-specified inclusion, selection, and exclusion criteria. SELECTION CRITERIA: PICO; P-women with low-risk pregnancy planned for induction of labor. I-Outpatient induction C-Inpatient induction O-Outcomes according to the core outcome set for induction of labor (COSIOL). DATA COLLECTION AND ANALYSIS: Pooled in meta-analyses. The certainty of evidence was assessed using the GRADE system. MAIN RESULTS: The 20 included studies, including 7956 women, showed an overall low incidence of adverse events and indicated comparable results for inpatient and outpatient induction, but the studies were underpowered for safety-related outcomes. Women's experiences of outpatient induction were mostly positive. Based on three studies, the economic costs consequence is inconclusive. CONCLUSIONS: Due to early randomization, heterogenic study design, and underpowered studies regarding safety outcome, the certainty of evidence is very low. It is uncertain whether outpatient induction affects the risk for neonatal and maternal complications.