Kenyan health stakeholder views on individual consent, general notification and governance processes for the re-use of hospital inpatient data to support learning on healthcare systems.

BACKGROUND: Increasing adoption of electronic health records in hospitals provides new opportunities for patient data to support public health advances. Such learning healthcare models have generated ethical debate in high-income countries, including on the role of patient and public consent and engagement. Increasing use of electronic health records in low-middle income countries offers important potential to fast-track healthcare improvements in these settings, where a disproportionate burden of global morbidity occurs. Core ethical issues have been raised around the role and form of information sharing processes for learning healthcare systems, including individual consent and individual and public general notification processes, but little research has focused on this perspective in low-middle income countries. METHODS: We conducted a qualitative study on the role of information sharing and governance processes for inpatient data re-use, using in-depth interviews with 34 health stakeholders at two public hospitals on the Kenyan coast, including health managers, providers and researchers. Data were collected between March and July 2016 and analysed using a framework approach, with Nvivo 10 software to support data management. RESULTS: Most forms of clinical data re-use were seen as an important public health good. Individual consent and general notification processes were often argued as important, but contingent on interrelated influences of the type of data, use and secondary user. Underlying concerns were linked to issues of patient privacy and autonomy; perceived risks to trust in health systems; and fairness in how data would be used, particularly for non-public sector re-users. Support for engagement often turned on the anticipated outcomes of information-sharing processes, as building or undermining trust in healthcare systems. CONCLUSIONS: As reported in high income countries, learning healthcare systems in low-middle counties may generate a core ethical tension between supporting a public good and respecting patient autonomy and privacy, with the maintenance of public trust acting as a core requirement. While more evidence is needed on patient and public perspectives on learning healthcare activities, greater collaboration between public health and research governance systems is likely to support the development of efficient and locally responsive learning healthcare activities in LMICs.

Patient Satisfaction in Neurosurgery Clinic.

BACKGROUND: National commercial surveys are used to assess patient satisfaction. However, the information obtained does not always correspond to the clinical situation and therefore may be inadequate to help improve a specific patient experience when through no fault of its design, results in low response rates and inadequate specifics. OBJECTIVE: The objective is to investigate patient satisfaction using real-time in-person patient experience survey responses at the end of a neurosurgical clinic visit and review the results from these survey responses and those from national commercial survey responses provided by the hospital for the ability to affect change. METHODS: This is a prospective study from October 2023 to December 2023 during which a paper copy of 10 questionnaires derived from a national commercial outpatient clinical survey was given to every unique patient who was neurologically capable of filling it out at the end of his or her neurosurgery clinic visit. The electronic medical record was used to collect patient demographics and details of the clinic visit. National commercial survey responses from July 2022 to November 2023 provided by the hospital were reviewed. RESULTS: A total of 149 patients were seen in the neurosurgery clinic from October 2023 to December 2023, 121 patients were given the in-person patient satisfaction survey, and the response rate was 100%. The mean age was 46.5 years with females constituted 45.5% of the patient sample. The visit type included 46 (38.0%) new patients, 53 (43.8%) returning patients, and 22 (18.2%) post-op patients, of which 45.5% presented with cranial pathologies. Comparing the patient satisfaction level between those seen by one provider and those seen by two providers, such as resident, or mid-level with attending, patients seen by two providers were less satisfied with "feeling respected by the providers" (4.92 vs. 4.64, p=0.0088), "feeling listened to by the providers" (4.84 vs. 4.50, p=0.0180), and "feeling appreciated that the providers discussed illness prevention" (4.72 vs. 4.29, p=0.0232). Due to a lack of necessary information from our national commercial outpatient clinic survey responses provided by the hospital, a direct comparison between the in-person survey and our national commercial outpatient clinic survey was not made. CONCLUSIONS: Patient satisfaction surveys when not given in real-time in-person run the risk of low response rate and lack of specifics to help guide providers in quality improvement. Our data supports the use of real-time in-person patient satisfaction surveys that not only increase response rate but also provide useful information to help improve patient experience.

Improving and Sustaining Resident Physician Handover.

Background Handoffs serve a critical patient safety function in the transition between caregivers. In 2006, the Joint Commission on Accreditation of Healthcare Organizations strongly recommended the implementation of "a standardized approach to 'handoff' communications, including an opportunity to ask and respond to questions." Numerous studies have investigated the quality and efficacy of patient handoffs and the utility of structured handoff curriculums, particularly in the context of patient safety and outcomes. Objective The pediatric residents at Penn State Health (PSH) did not utilize a formal written or verbal handoff tool. Our study facilitated the design of a comprehensive handoff curriculum, including verbal and written components, and the implementation of faculty and multidisciplinary care team involvement coupled with resident training and observations. We investigate the impact of this curriculum longitudinally utilizing validated tools completed by external observers as well as the residents themselves. Methods Prior to SAFETIPS being implemented, residents at a mid-sized Pediatric program were observed giving handovers at various intervals to understand baseline habits. Residents were then educated with the SAFETIPS curriculum and again observed. Trained observers of the handover process completed a validated evaluation form concentrating on seven key domains necessary for effective handover and communication; residents involved in the handover also completed a validated evaluation form. Consent for the project was implied with the observer's presence during the process and our study was exempt from full IRB consideration given its quality improvement design. A mix of summary statistics, stacked dot plots, mixed effects regression, and joint F tests were used to analyze data. Results Mean values on all sections of the handover evaluation Likert scale completed by trained observers tended to increase over time; the variance in responses was likewise much smaller at later time periods. Similarly, all sections of the evaluation tools completed by the resident physicians themselves showed significantly increased scores from pre- to post-implementation of our curriculum. Data revealed a plateauing of results toward later time points suggestive of skills mastery and sustained improvements. Conclusion Our findings suggest that the introduction of a structured handoff curriculum correlated with improved communication among residents, and such improvements were sustained over time.

Lessons From the Pandemic for Hand Surgery in Wales.

Aims In March 2020 the World Health Organisation (WHO) declared the COVID-19 virus a global pandemic. The United Kingdom's National Health Service (NHS) was placed under unprecedented pressure and hospitals were forced to adapt their working practices to continue offering world-leading healthcare. This project aims to highlight the lessons learnt within hand surgical departments throughout Wales. Using this knowledge, we can consider how these lessons can be implemented in both emergency and elective hand practice. Methods A qualitative questionnaire was distributed to hand consultants working across Health Boards within Wales during the pandemic. The questionnaire encompasses the impact of the pandemic on usual practices and what local departmental changes have been implemented in response to patient needs. Results Across the Welsh Health Boards, we received 12 of 19 consultant responses achieving a 63% response rate and captured data from five of seven (71%) major health boards. The questionnaire revealed that 100% of respondents changed their routine management of elective cases whilst 83% changed their management of hand trauma. 50% reported the need to issue updated management guidelines to junior doctors. The major highlighted lessons were the importance of a dedicated hand fracture clinic, coupled with a ring-fenced day-surgical unit (offering regional anaesthetic support) to manage trauma and elective patients independently from general trauma. Conclusion This qualitative research demonstrates that the pandemic drove the restructuring of many hand departments enabling us to find new, efficient ways of working. We must take these lessons forward to tackle the ever-growing waiting list, increased patient expectations and increasingly complex workloads.

Impact of Raising Awareness and Providing Feedback on Compliance to Antibiotic Prescription Guidelines in Pediatric Inpatients.

INTRODUCTION:  Antibiotics are vital in managing infectious diseases that significantly burden health infrastructure in a developing country like India. However, the widespread and irrational use of antibiotics has given rise to the menace of antibiotic resistance that threatens to take us back to the pre-antibiotic era. Our study aimed to evaluate the baseline compliance to antibiotic policy in the pediatric inpatient ward and analyze the impact of interventions on compliance with the policy. MATERIALS AND METHODS:  The prospective study was done at MGM Medical College and Hospital, Aurangabad. The study included infants and children from one month to 18 years of age admitted to the pediatric ward. Patients' prescription charts were evaluated in 375 patients during the first three months of the study, and prescribed antibiotics were recorded and compared with standard treatment guidelines. The intervention included awareness, educational, and feedback sessions regarding antibiotic prescription policies. The antibiotics prescribed were analyzed in 375 patients during the next three months. RESULTS:  We found out that in the pre-intervention and post-intervention phases, out of a total of 375 patients, 60% and 46.1% were on antimicrobials, respectively. Out of those who were on antimicrobials, only 46% were compliant with the policy initially. That increased to 61% after the intervention. CONCLUSION:  Awareness, education, and feedback regarding antibiotic prescription policy as an intervention helped increase compliance, though not to the desired level of more than 90%. Continuous cycles of awareness and feedback help achieve better compliance.

CRABEL Score Assessment for Oral Surgery Excision Biopsy Case Notes of Oral Squamous Cell Carcinoma.

Background Oral surgical records contain all the information regarding a patient, including their history, clinical findings, diagnostic test results, pre-and postoperative care, progress, and medication. Notes that are properly drafted will help the physician argue that the course of therapy is appropriate. Several tools have been created for auditing clinical records; one such tool that may be used for any inpatient specialty is the CRABEL score system developed by CRAwford-BEresford-Lafferty. Aims This research aimed to evaluate the oral surgical records using the CRABEL scoring system for quality assessment. Materials and methods The case audit was performed from June 2023 to February 2024 for all Excisional biopsy cases of Oral Squamous Cell Carcinoma. Relevant data was retrieved from the Dental Information Archival Software (DIAS) of Saveetha Dental College and Hospitals, Chennai. It was evaluated by two independent oral pathologists trained in CRABEL scores. Two consecutive case records were evaluated. Fifty points were given for each case record. Scoring was given according to initial clerking (10 points), subsequent entries (30 points), consent (5 points), and discharge summary (5 points). The total score was calculated by subtracting the total deduction from 100 to give the final score. The mean scores of the case records were calculated. A descriptive statistical analysis was done with Statistical Package for Social Sciences (SPSS version 23.0; IBM Inc., Armonk, New York). Inter-observer agreement and reliability assessment were made using Kappa statistics.  Results From the DIAS in that period, the data of 52 cases were retrieved and reviewed. There was no proof of a reference source in the audited records, and one deduction was made to the reference score in the initial clerking, and the effective score was 98 out of 100. The mean values of 52 case records were also 98 out of 100. The observed kappa score was 1.0. There was no inter-observer bias in the scoring criteria. Both observers also gave the same scoring. Conclusion Our study illustrates that oral surgery case records in our institution were found to be accurate, as they maintained 98% of the CRABEL score value. Frequent audit cycles will help in standardizing and maintaining the quality of oral surgery case records.

Caseworker Cultural Mediator Involvement in Neurocritical Care for Patients and Families With Non-English Language Preference: A Quality Improvement Project.

Objective To describe Harborview Medical Center's experience with the involvement of caseworker cultural mediators (CCM) for patients requiring neurocritical care. Methods Using univariate and multivariate analysis (model adjusted for age, Glasgow Coma Scale score (GCS), Sequential Organ Failure Assessment (SOFA) Scores, mechanical ventilation, transition to comfort measures only (CMO), and death by neurologic criteria), we examined CCM team members' involvement in the care of Amharic/Cambodian/Khmer/Somali/Spanish/Vietnamese patients admitted to our neurocritical care service between 2014-2022, factors associated with CCM utilization, and changes in CCM utilization after a QI initiative was implemented in 2020 to encourage healthcare providers to consult the CCM team. Results Compared to eligible patients (n=827) who did not receive CCM referral, patients with CCM involvement (n=121) were younger (49 [interquartile range, IQR 38,63] vs. 56 [IQR 42,68] years, p = 0.002), had greater illness severity (admission GCS 8.5 [IQR 3,14] vs. 14 [IQR 7,15], p < 0.001, SOFA scores (5 [IQR 2,8] vs. 4 [IQR2,6], p = 0.007), and more frequently required mechanical ventilation (67% vs. 40%, odds ratio, OR 3.07, 95% CI 2.06,4.64), with higher all-cause mortality (20% vs. 12%, RR 1.83, 95% CI 1.09, 2.95), and with a higher rate of transition to CMO (11.6% vs. 6.2%, OR 2.00, 95% CI 1.03;3.66). The CCM QI initiative was independently associated with increased CCM involvement (aOR 4.22, 95% CI [2.32;7.66]). Overall, 4/10 attempts made by CCMs to reach out to the family to provide support were declined by the family. CCMs reported providing cultural/emotional support (n=96, 79%), end-of-life counseling (n=16, 13%), conflict mediation (n=15, 12.4%), and facilitating goals of care meetings (n=4, 3.3%). Conclusions Among eligible patients, CCM consultations appeared to occur in patients with higher disease severity. Our QI initiative increased CCM involvement.

Adult Hospitalists' Knowledge of Radiation Oncology in an Independent Nonacademic Healthcare System in Albuquerque, New Mexico.

Radiation oncology (RO) plays a crucial role in cancer care; cancer patients often undergo their initial diagnostic study by general physicians. However, studies have shown that most physicians are uncomfortable referring cancer patients to radiation therapy (RT). To assess the knowledge of RO among non-oncology physicians, we sent invitations to complete an online survey that required the responders to self-rate their understanding of RT and objective assessment. The survey was targeted at hospitalists and primary care physicians. Forty physicians responded to the survey, and 89.7% practiced primarily as hospitalists, with 67% being Internal Medicine graduates. Fifty percent of physicians have referred patients to RO before, although more than 90% have not done additional CME (continuing medical education) in Oncology. More than 50% of recent graduates (one to five years post-residency) self-rated themselves as "not knowledgeable" when it comes referral process to RO as well as general knowledge regarding RT. Factors, such as "type of cancer," "patients' wishes," and "life expectancy," are most cited as factors influencing the decision for a referral.

Compliance With the Royal College of Radiologists Guideline for Actionable Reporting and Its Impact on Patient Care: A Retrospective Analysis of Reporting Practices From a Major Trauma Center.

Introduction Prompt diagnosis forms the mainstay of management of any patient arriving at the hospital. In developed settings, apart from clinical assessment, imaging in the form of computed tomography (CT) scan plays a vital role in arriving at the patient diagnosis. The reporting should follow pre-defined Royal College of Radiologists (RCR) standards to improve the quality of the diagnostic process. Objectives To identify the compliance of reporting as per the RCR standards for the communication of radiological reports and fail-safe alert notification. Materials and methods A retrospective review of body CT scans was done in two cycles within a span of three months. A total of 100 randomized scans were assessed in each cycle, both from the A&E (accident and emergency) and inpatients. Normal scans and outpatient scans were excluded from the study. Data were collected using the online portal (CRIS) and statistical analysis was performed. Results After the first cycle of the audit, 95 reports out of 100 met the standard RCR criteria. After the second cycle, 97 reports met the criteria of the audit. One inpatient scan and two A&E reports did not meet the specified criteria in the second cycle. Conclusion After the two cycles of the audit carried out over three months, we were able to achieve almost 97% of reporting standards as compared to 95% obtained previously through a quality improvement project and create awareness.

Value-Based Care and Anesthesiology in the USA.

Value-based care, prioritizing patient outcomes over service volume, is steering a transformative course in anesthesiology in the United States. With the rise of this patient-centric approach, anesthesiologists are adopting dynamic roles to meet the demands of medical institutions, insurers, and patients for high-quality, cost-effective care. The urgency for this transition is accentuated by persistent challenges in reducing postoperative mortality rates and surgical complications, further spotlighted by the coronvirus disease 2019 (COVID-19) pandemic. Anesthesiologists engage in preoperative optimization, personalized care delivery, and evidence-based practices, bolstering their influence in the perioperative environment. Their collaboration with perioperative stakeholders propels the shift toward a value-driven healthcare landscape. This review analyzes the implementation of value-based care in American anesthesiology, assesses the significance of technology in enhancing its delivery, and outlines potential strategies for improving its application.

Male Urethritis in Primary Care: Real-World Evidence From a Portuguese Center.

Introduction Early diagnosis and treatment of male urethritis are fundamental for preventing complications and further transmission. Primary healthcare services are the first point of contact for patients. This study aimed to assess the practice and compliance of Unidade Saúde Familiar Conde Lousã (USF CL) with best clinical practices. Materials and Methods A retrospective study was undertaken on male urethritis cases at USF CL from January 2018 to March 22, 2021, identified using the International Classification of Primary Care (ICPC) coding system. We established quality criteria encompassing treatment, diagnostics, and reporting. A "sufficiency index" was introduced as a performance metric, which was designed to offer a multiparametric assessment of adherence to these criteria. Results Of 77 cases, 60 were included, averaging 27 years of age. In all, 40.7% showed treatment adequacy, with a sufficiency index of 0.28 for epidemiological characterization and 0.52 for co-infection screening. Prevention measures indexed at 0.28, with 27.1% diagnostic notifications. Conclusion The study reveals gaps in managing male urethritis at USF CL, underscoring the need for standardized guidelines and better diagnostic tools in primary care. Based on these results, a new multicentric specialized sexually transmitted infections clinic was created within our unit in collaboration with a tertiary hospital [Centro Hospitalar Universitário Lisboa Central (CHULC), Lisbon, Portugal] and the national laboratory center [Instituto Nacional de Saúde Doutor Ricardo Jorge (INSA), Lisbon, Portugal].

Improving the Hospital Transfer Process for Acute Type A Aortic Dissections.

Patients with acute type A aortic dissection who arrive at hospitals that lack the facilities to treat them must be transferred to a tertiary care facility to receive treatment. The transfer process involves a checkpoint at which the transfer is accepted or denied. Delays in making this decision may lead to suboptimal health outcomes. In light of this, the goal of this project was to devise a way to reduce the time to decision of transfer requests for patients with an acute type A aortic dissection. The project followed the Define-Measure-Analyze-Improve-Control (DMAIC) approach. To better understand the process, data were obtained from the University of Texas Southwestern Medical Center regarding reasons for patient transfer cancellation and the average time until a transfer was denied or accepted. After data analysis, a fishbone diagram was used to display 23 root causes of the delays in time to decision of the transfer request. These were narrowed down to the following four significant causes using a nominal voting technique: (1) no standard on disease-specific information for the handoff, (2) lack of a real-time database, (3) incompatible electronic health record system between facilities, and (4) multiple communication handoffs causing confusion. Solutions to each root cause were evaluated using a solution selection matrix. The final two solutions proposed for implementation were as follows: (1) to establish checklists of required documents and patient transfer criteria and (2) to create a regional database to provide real-time information on hospital capacity.

A Clinical Audit on the Indications for Intervention With Transcatheter Aortic Valve Implantation Over Surgical Aortic Valve Replacement in Aortic Stenosis Patients in Mohammed Bin Khalifa Bin Salman Al Khalifa Specialist Cardiac Centre.

Introduction Transcatheter aortic valve implantation (TAVI) is a novel treatment strategy used to treat patients with symptomatic aortic stenosis. It utilizes a percutaneous approach and is preferred over surgical aortic valve replacement (SAVR) in patients at high surgical risk. The aim of this study was to audit the indications of the intervention with TAVI over SAVR in Bahrain Defence Force Hospital, Mohammed Bin Khalifa Bin Sulman AlKhalifa Cardiac Centre (BDF-MKCC), as well as note the outcomes of patients who underwent TAVI. Methods The indications for allocating aortic stenosis patients to TAVI over SAVR in BDF-MKCC were studied with regard to the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery (ESC/EACTS) guidelines published in 2017. Data from 82 patients, which accounts for all patients who underwent TAVI, were collected retrospectively from electronic medical records and the percentage of compliance was calculated and analyzed. Results The compliance percentages of the 23 parameters for the intervention with TAVI that have been set by the ESC/EACTS are calculated, where BDF-MKCC were fully adherent to 12 out of the 23 standards. Moreover, the total number of patients that are compliant with all standards is 13 out of 82 (15.85%) compliant patients. Conclusion The centre showed non-compliance to many of the published standards. Hence, we created a checklist to ensure that the international guidelines are followed. We are looking forward to re-audit this aspect in the near future, to make certain that changes were done. We would also like to do a comparative study to compare the patients' outcomes before and after implementing the 2017 ESC/EACTS guidelines. Furthermore, we call for further studies to be conducted in this field and that is to evaluate the standards themselves as well as the safety of TAVI in those who are not eligible for it according to the ESC/EACTS.

Referral for Cardiac Amyloidosis in Patients Who Underwent Transcatheter Aortic Valve Replacement: Results of the Quality Outcome Project.

Background Transthyretin cardiac amyloidosis (ATTR) is an important comorbidity present in severe aortic stenosis (AS). The purpose of this study was to raise awareness of ATTR in patients who underwent transcatheter aortic valve replacement (TAVR) for severe AS among healthcare providers and patients. Methodology We reviewed 197 consecutive TAVR cases performed from 2019 to 2020. Adapting predefined high-risk features for ATTR based on prior literature, we contacted the patients to discuss our clinical suspicion of ATTR and offered a referral to a cardiac amyloid specialist. Results We identified 125 (69.4%) patients who had high-risk features of ATTR. Of the 105 patients contacted, 44 patients agreed to referral, 46 patients were not able to be contacted after several attempts, and 15 patients declined referral. Of the 44 patients who agreed to the referral, 20 patients completed the evaluation for cardiac amyloidosis, all of whom were negative for transthyretin and light-chain cardiac amyloidosis. Conclusions Our attempt to detect ATTR in prior TAVR patients was unsuccessful two to three years post-TAVR. We believe that early detection of cardiac amyloidosis close to the timing of TAVR is important and the most effective means.

An Audit of Inpatient Consultation-Liaison Psychiatry Services at an Inner New York City Safety Net Hospital.

Background Our study's primary objective is to audit the resource utilization of a consultation-liaison (CL) psychiatry service in an inner New York City safety net hospital. This cross-sectional, observational study was conducted as a subset of a quality improvement project at the hospital to investigate the characteristics of the emergent nature of consults, types, and the specialty from which the referral was placed to the CL services. This study aims to improve the efficacy of our consult process by improving the appropriateness and precision of consult requests. Methodology This cross-sectional, observational study was reviewed and approved by the Institutional Review Board under a quality improvement exemption. The study investigated the EPIC electronic medical record data for characteristics of consult referrals in the third quarter of 2019 from July 1, 2019, to September 30, 2019. A total of 629 consults were recorded during this period. We excluded follow-up calls, duplicate data rows, and patients with missing data points; the final consults were 421. Patients who required more than one new consult (follow-up excluded) within 90 days were considered; thus, the total number of patients who were included in the study was 327. Results Of the 421 consults identified in the dataset for review, only 45.8% were valid consults, 32.8% were not valid, and 21.4% were uncertain. Further, the most common department from which consults were placed was Medicine (73.2%), followed by Surgery (12.8%), Obstetrics/Gynecology (9%), Critical Care (3.6%), and, finally, Pediatrics (1.4%). Conclusions The study overviews the quality of general consults for the CL psychiatry service and how the CL staff manages it. It also provides an idea about the number of consults that can be comprehensively addressed.

Can Antibiotic Stewardship Be Achieved by Utilizing the Stewardship Through Educating Patients (S.T.E.P.) Process?

BACKGROUND: Despite research and efforts to mitigate bacterial resistance, antibiotic overprescribing continues to occur, often due to real or perceived expectations of patients.  Objective: The purpose of this study was to determine: (1) if there's an association between the provider's patient education efforts and the patient's satisfaction, and (2) the research participant's subsequent behavior concerning antibiotic prescriptions, by utilizing the Stewardship Through Educating Patients (S.T.E.P.) process for positive prescriptive change. The S.T.E.P. program features straightforward, simple education via face-to-face counseling at patient encounters, along with presenting applicable printed educational pamphlets from the Centers for Disease Control and Prevention (CDC). These two interventions were utilized in this study with research participants from the healthcare provider, with education focused on appropriate antibiotic use in the treatment of adults diagnosed with common illnesses such as an upper respiratory infection (the common cold), acute sinusitis, and acute bronchitis, which oftentimes are viral in origin. METHOD: This Quality Improvement (QI) interventional study utilized the researcher's direct face-to-face patient education and CDC printed materials as a measure of antibiotic prescribing as a primary outcome, with patient satisfaction as a secondary outcome via convenience sampling of 40 hospital employees who utilized a free hospital-based employee healthcare clinic. RESULTS: Patient-teaching by this study's researcher, along with supplemental printed patient education material from the CDC that were given to research participants during an initial medical encounter, were effective interventions used in reducing antibiotic prescribing, as evidenced by a positive patient satisfaction in 95% of research participants. CONCLUSIONS: Antibiotic use in the treatment of adults diagnosed with common illnesses such as an upper respiratory infection (the common cold), acute sinusitis, and acute bronchitis, may be safely reduced by using a combination of patient-education and clinician intervention.

The National Audit of Primary Biliary Cholangitis (PBC) in the United Kingdom: Defining the Audit Dataset and Data Collection System.

Primary biliary cholangitis (PBC) is a debilitating chronic liver disease that progresses to cirrhosis with attendant complications in a substantial proportion of patients. It is a major cause of liver-related morbidity and mortality in the United Kingdom (UK). The British Society of Gastroenterology (BSG) published guidelines on PBC management, which included key audit standards. Therefore, we propose the first UK-wide audit of the management of PBC, sanctioned by the BSG and the British Association for Study of the Liver (BASL), to benchmark NHS trusts and health boards against these audit standards as a guide to targeted improvement in the delivery of PBC-related health care.

Evaluating the Appropriateness of Pulmonary Embolism Admissions in a Community Hospital Emergency Department.

Pulmonary embolism (PE) is a diagnosis on the broader spectrum of venous thromboembolic (VTE) disease. The diagnostic key for clinicians is detecting which patients have a "high risk" of complications or mortality and who are in the "low-risk" population. The Pulmonary Embolism Severity Index (PESI) and HESTIA scores are validated risk stratification tools to determine if patients diagnosed with PE can be successfully managed in the outpatient versus inpatient setting. We aimed to investigate the appropriateness of PE admissions to our institution based on the risk stratification recommendations from PESI and HESTIA scores. We retrospectively identified 175 patients admitted with a diagnosis of PE over one year at our hospital. Baseline demographics, length of admission, and admitting diagnoses were collected for all patients included in this study. PESI and HESTIA scores were then calculated for all included patients. The average PESI score was 91.65 (95% confidence interval: 86.33, 96.97). There were 87 patients (49.7%) that had a low or very low PESI score of fewer than 85 points. Fifty-seven patients (33.7%) presented with a HESTIA score of 0. The risk stratification score indicates these patients as low risk, and appropriate for outpatient management. However, they were instead admitted to the hospital which contributes to increased costs, risk of adverse events, etc. There were 0 mortalities reported for patients in the "low or very low risk" groups, with four reported mortalities in the "very high risk" groups.  In our cohort, 33.7%-49.7% of admissions for PE were risk-stratified as "low risk" and qualified for outpatient management based on HESTIA and PESI risk stratification scores, respectively. The underutilization of validated risk scores upon initial diagnosis of PE may lead to worse outcomes and increased healthcare expenditure.

Increasing Fecal Immunochemical Test Return Rates by Implementing Effective "Reminder to Complete Kit" Communication With Participants: A Quality Improvement Study.

Background The incidence of colorectal cancer (CRC) in the United States is increasing. It remains the second leading cause of cancer death in the United States for men and women combined, mainly due to underutilization of screening methods. The American Cancer Society now recommends that adults aged 45 years and older with an average risk of CRC undergo regular screening with either a high-sensitivity stool-based test or structural (visual) examination, depending on patient preference and test availability. The primary objective of this quality improvement project was to determine if reminder methods, such as telephone or letter reminders, increased the return rate of fecal immunochemical tests (FIT) for CRC screening. Methodology At public outreach events and daily clinics in the West Texas Panhandle area, participants in the GET FIT program were provided with FIT kits after completing the education on CRC. Participants who fit the inclusion criteria and had received a FIT kit from the program were included. They were instructed on how to perform the test and mail it back. Participants who did not return the completed kits within two weeks were reminded either through (1) a reminder letter, (2) telephone, or (3) a combination of letter reminder and telephone call every two weeks (±three days) for 60 days or five attempts to contact. We de-identified and analyzed the FIT kit return data from April-September 2019 before analyzing these reminder methods. We then calculated the change in return rates from October 2019 to March 2020. Our goal was to increase the FIT return rates by 25% compared to the baseline return rate. Results The pre-intervention return rate of kits for April-September 2019 was 61.52%, and the post-intervention return rate for October 2019-March 2020 was 71.85%. This rate was equal to an approximately 16.79% increase in return rates that was statistically significant (p < 0.01). There was a significant difference in the method of reminder between the two groups, but no significant differences in gender and race/ethnicity between the two groups. There was a significant difference in return rates between race/ethnicities in the October-March cohort with black and Hispanic participants having the highest return rates of 82.3% and 77.25%, respectively. Conclusions FIT remains one of the primary options for CRC screening. Due to its lower cost and noninvasiveness, FIT was offered to patients at average risk. We demonstrated an increase in return rates, although we did not meet our target return rate goal for this project. This study was limited due to a gradual increase in coronavirus disease 2019 (COVID-19) cases and a subsequent shift and conversation of ongoing research into COVID-19.

Quality Improvement of a Hip Injection Service.

Background Osteoarthritis is a substantive burden on the population and National Health Service (NHS) in the United Kingdom. A recent systematic review suggests that intra-articular steroid injections are an efficacious conservative treatment modality. The NHS Constitution states that "patients should wait no longer than 18 weeks from GP referral to treatment." An NHS hospital trust failed to meet this standard in a quarter of patients waiting for an intra-articular steroid injection of the hip. Strategies were considered to improve the time from referral to treatment (RTT). The aim of this quality improvement project was to improve the efficiency and capacity of the injection list. Materials and methods Patients who underwent an injection on a list between January and April 2019 were identified. Data were retrospectively collected and included the sites of injection and waiting times. Proformas for documentation and discharge summaries were introduced. Time taken for each appointment pre- and post-intervention were compared with the aim to increase the number of patients per list. Results Thirty-six (26%) of 138 patients experienced delays beyond 18 weeks from RTT. The mean (standard deviation [SD]) number of weeks waiting for an injection from the time of referral was 14 (6). The mean (SD) time for each appointment was 12 minutes 36 seconds (7 minutes 36 seconds) pre-intervention and 8 minutes 36 seconds (3 minutes 12 seconds) post-intervention. Discussion and conclusion Our standardized proformas led to an improvement in efficiency by reducing the time taken for documentation and capacity by subsequently increasing the number of patients per list.