Emergency Medicine Palliative Care Access (EMPallA): Protocol for a multicentre randomised controlled trial comparing the effectiveness of specialty outpatient versus nurse-led telephonic palliative care of older adults with advanced illness

Introduction Emergency department (ED)-initiated palliative care has been shown to improve patient-centred outcomes in older adults with serious, life-limiting illnesses. However, the optimal modality for providing such interventions is unknown. This study aims to compare nurse-led telephonic case management to specialty outpatient palliative care for older adults with serious, life-limiting illness on: (1) quality of life in patients; (2) healthcare utilisation; (3) loneliness and symptom burden and (4) caregiver strain, caregiver quality of life and bereavement. Methods and analysis This is a protocol for a pragmatic, multicentre, parallel, two-arm randomised controlled trial in ED patients comparing two established models of palliative care: nurse-led telephonic case management and specialty, outpatient palliative care. We will enrol 1350 patients aged 50+ years and 675 of their caregivers across nine EDs. Eligible patients: (1) have advanced cancer (metastatic solid tumour) or end-stage organ failure (New York Heart Association class III or IV heart failure, end-stage renal disease with glomerular filtration rate /min/m2, or global initiative for chronic obstructive lung disease stage III, IV or oxygen-dependent chronic obstructive pulmonary disease); (2) speak English; (3) are scheduled for ED discharge or observation status; (4) reside locally; (5) have a working telephone and (6) are insured. Patients will be excluded if they: (1) have dementia; (2) have received hospice care or two or more palliative care visits in the last 6 months or (3) reside in a long-term care facility. We will use patient-level block randomisation, stratified by ED site and disease. Effectiveness will be compared by measuring the impact of each intervention on the specified outcomes. The primary outcome will measure change in patient quality of life. Ethics and dissemination Institutional Review Board approval was obtained at all study sites. Trial results will be submitted for publication in a peer-reviewed journal

Long-term renal function and hypertension in adult survivors of childhood sarcoma

Aim: Little data is available on long-term renal impairment in survivors from childhood sarcoma. We investigated the prevalence of renal impairment and hypertension after very long-term follow-up in survivors who reached adulthood after treatment for childhood sarcoma. Methods. A cross-sectional single center study was performed. Outcomes included estimating glomerular filtration rate (eGFR), albuminuria, glycosuria, serum phosphate and magnesium, tubular reabsorption phosphate (TRP), chronic kidney disease (CKD) according to the “Kidney Disease: Improving Global Outcomes” (KDIGO) guidelines and blood pressure (BP). Results: Out of 87>5-year sarcoma survivors, 30 adults (10F/20M, median age at diagnosis 9 years, median age at investigation 26 years, median follow-up 16 years, mean 19 years) were identified. Renal impairment was detected in 4 cases (13.3%); 3 of these fulfilled the criteria for CKD. Among the adult survivors, a subgroup of 15 cases (50%) had received ifosfamide without confounding factors such as a diagnosis of genito-urinary rhabdomyosarcoma or administration of other potentially nephrotoxic chemotherapy (platinum-based drugs or methotrexate); no renal dysfunction was detected in this subgroup. In the whole cohort of sarcoma survivors, hypertension was diagnosed in 4 cases (13.3%); BP was significantly correlated with body mass index [p 0.014] Conclusion: In our series of adult survivors treated for a diagnosis of sarcoma in their childhood, the prevalence of CKD was 10%. We found survivors treated with ifosfamide as the only nephrotoxic agent did not present glomerular or tubular toxicity at long term follow-up, but further studies including a larger number of cases are required to confirm it.

Implementation of Oncology Standardized Scheduling Bundle Impacting Staff Productivity and Patient Satisfaction

BACKGROUND: Patients having timelyaccess to healthcare services is the entryway to quality of care and patient safety. Timely access is essential in cancer treatment and often requires complex scheduling requiring multiple, highly coordinated, time sensitive appointments. To facilitate optimal clinical care, timely appointment scheduling must be patient-centered. With the heavy scheduling workload growing at the the Cancer Network at Froedtert & the Medical College of Wisconsin and recognition of timely scheduling as a quality indicator, the need to examine the workflow and improve the process became apparent. METHODS: The goal of the quality improvement project was to provide patients with individualized and timely scheduling of appointments. The development and implementation of a standardized oncology scheduling bundle began with a SWOT analysis and the use of Donebedian Model to organize the improvement process. A scheduling bundle that included consistent scheduling practices and staff education to drive patient satisfaction scares and scheduling staff productivity metrics was developed. As well, a productivity dashboard was developed. RESULTS: The implementation of a standardized oncology scheduling bundle showed positive results with both quantative and qualitative metrics. There was positive shift in average scheduling staff productivity and staff turnover decreased pre and post implementation. Additionally, there was positive changes in feedback from patients, staff, and physicians. CONCLUSION: With the implementation of the standardized oncology scheduling bundle, patients are receiving timely, optimal, individualized clinical care. Additionally, there is now a standardized process for scheduling staff creating efficient and effective workflows

Advancing Physician Performance Measurement: Using Administrative Data to Assess Physician Quality and Efficiency

Summarizes national initiatives to advance the practice of standardized measurement and outlines goals for developing a method for tracking efficiency and quality that will reward physicians and enable patients to make informed healthcare choices

Pediatric Hematology/Oncology Outpatient Care: the Effect of a Standardized Collaborative Medication Reconciliation Process

Pediatric patients are at an increased risk for medication errors and can benefit from processes that facilitate and promote medication safety (Stone et al., 2010). Medication reconciliation (Med Rec) is a valuable tool in improving patients’ medication safety and reducing adverse drug events (The Joint Commission, 2015). The purpose of this evidence-based practice (EBP) project was to improve the accuracy of the Med Rec process in a Midwestern pediatric hematology/oncology outpatient clinic by developing, promoting, and evaluating a standardized, collaborative Med Rec process. The Stetler EBP model guided the implementation of the intervention, with the goal of integrating current evidence into current practice. Kotter’s Model of Change laid the theoretical foundation for successful implementation of a current practice change. This EBP project intervention included a patient and team member component. The patient component consisted of a verbal call reminder to bring medications to the visit, a patient handout emphasizing the importance of medication safety and reconciliation, and patient education regarding Med Rec process. The team member component included education regarding the importance of the Med Rec process and updates regarding Med Rec accuracy. The outcomes measured included the number, type, and severity of medication discrepancies and the number of voluntarily reported medication errors. Data were collected during Phase 1 (pre-intervention) and Phase 2 (post-intervention) by the physicians and the project leader (PL). These data were analyzed using chi-square tests. The intervention lead to a significant increase in the number of accurate Med Recs reported by the physicians between Phase 1 (n = 50, 70%) and Phase 2 (n = 65, 90.8%) (X2 = 8.167, df = 1, p = .004). An insignificant decrease in the number of accurate Med Recs was reported by the PL between Phase 1 (73.1%) and 2 (72.5%) (X2 = .003, df = 1, p = 0.959). Physicians reported more incorrectness errors in Phase 1 (73.3%) and Phase 2 (83.3%) than incompleteness errors (X2 = .481, df = 1, p = .786). PL reported more incompleteness errors in Phase 1 (71.4%) and Phase 2 than incorrectness errors (81.8%) (X2 = 1.670, df = 2, p = .434). The majority of Med Rec inaccuracies were classified as minor during Phase 1 and 2 by the physicians (X2 = .827, df = 2, p = .363) and the PL (X2 = 1.039, df = 1, p = .308). No inaccurate Med Rec was classified as severe by physicians or the PL. Finally, there were no voluntary medication errors were reported during the duration of the EBP project. Revision and replication of this EBP project would be helpful in further improving Med Rec accuracy in this setting

Impact of the COVID-19 pandemic on patients suffering from musculoskeletal tumours

Background The aim of the current study was to evaluate the impact of the coronavirus disease (COVID-19) pandemic on musculoskeletal tumor service by conducting an online survey of physicians. Methods The survey was conducted among the members of the ISOLS (International Society of Limb Salvage) and the EMSOS (EuropeanMusculo-Skeletal Oncology Society). The survey consisted of 20 questions (single,multiple-response, ranked): origin and surgical experience of the participant (four questions), potential disruption of healthcare (12 questions), and influence of the COVID-19 pandemic on the particular physician (four questions). A matrix with four different response options was created for the particular surgical procedures). Results One hundred forty-nine physicians from five continents completed the survey. Of the respondents, 20.1% and 20.7% stated that surgery for life-threatening sarcomas were stopped or delayed, respectively. Even when the malignancy was expected to involve infiltration of a neurovascular bundle or fracture of a bone, still 13.8% and 14.7% of the respondents, respectively, stated that surgery was not performed. In cases of pending fractures of bone tumors, 37.5 to 46.2% of operations were canceled. Conclusion The SARS-CoV-2 pandemic caused a significant reduction in healthcare (surgery, radiotherapy, chemotherapy) for malignancies of the musculoskeletal system. Delaying or stopping these treatments is life-threatening or can cause severe morbidity, pain, and loss of function. Although the coronavirus disease causes severe medical complications, serious collateral damage including death due to delayed or untreated sarcomas should be avoided