PTH-32 development of a novel electronic referral grading & triage system

Introduction: prior to Covid-19, demand for secondary care appointments continued to rise year on year suggesting unsustainable future post-pandemic demand. Now is thus the right time to invest in triage and clinical pathway innovation.Methods: anew fully-integrated digital triage system was built at our institution allowing for document upload and electronic triage. Data pertaining to referral time, triage decision, outpatient appointments and direct-to-test was extracted from the backend to plot empirical cumulative distribution functions, interquartile ranges and allow statistical comparison using the Kruskal-Wallis’ test.Results: we analysed the first 704 luminal Gastroenterology referrals through the new triage system with the following sub-specialty classifications: Iron deficiency anaemia (IDA) – 200, Upper gastrointestinal symptoms (UGI) – 152, Inflammatory bowel disease (IBD) – 116, Irritable bowel syndrome (IBS/Functional) – 95, Lower gastrointestinal symptoms/change in bowel habit alone (LGI/CIBH) – 59, Coeliac – 27, Surgical – 25, Complex Functional – 12, Intestinal failure (IF/Nutrition) – 12, Hepatology – 4. 664 (95%) of referrals were accepted with 179 (27%) being sent direct to test. Of these only 42 (23.5%) had a subsequent clinic appointment booked, vs 436 (90%) for those not going direct to test. In addition, sending patients direct to test increased the proportion of subsequent routine clinic appointments from 55% to 70%. Median timelag from referral to grading was four days with grading taking a single day and appointments occurring 17 days later on average. Direct-to-test was most common amongst patients in the UGI (52.6%) and IBD (50%) sub-cohorts. This was significantly different vs other groups at the (p<0.05) level. [PTH-32 Figure 1 Subspecialty Referrals vs Direct-To-Test Numbers not included].Conclusions: using a system as described here substantially improves data capture and efficiency. Direct to test reduces both need for clinic appointments and the urgency of subsequent appointments. IBD and UGI are the subspecialties most likely to benefit from direct to test approaches. IDA could be another suitable specialty and the plan is to address this in the future

Cervical spinal degenerative disease in multiple sclerosis

Background and purpose: root and cord irritation from cervical spinal degenerative disease (SDD) may share clinical features with progressive multiple sclerosis (MS), so diagnostic overshadowing may occur. We hypothesized that cervical stenotic SDD is commoner in people with progressive MS, compared to controls.Methods: a retrospective case-control study of 111 cases (56 with progressive MS and 55 age- and sex-matched controls) was conducted. Five types of cervical SDD (disc degeneration, posterior disc protrusion, endplate changes, canal stenosis and foraminal stenosis) were assessed objectively on magnetic resonance imaging using published scales. Multivariable regression analysis was performed.Results: moderate-to-severe cervical spinal degeneration occurred more frequently in progressive MS, compared to controls. In multivariable regression, foraminal stenosis was three times more likely in progressive MS (odds ratio 3.20, 95% confidence interval 1.27, 8.09; p = 0.014), and was more severe (p = 0.009). This finding was confirmed on retrospective evaluation of clinical radiology reports in the same population. Foraminal stenosis was twice as likely in progressive MS, compared to relapsing-remitting MS.Conclusions: people with progressive MS are susceptible to foraminal stenosis. A higher index of suspicion for cervical SDD is required when appropriate neurological symptoms occur in the setting of progressive MS, to guide appropriate treatment or monitoring

Automated data cleaning of paediatric anthropometric data from longitudinal electronic health records: protocol and application to a large patient cohort

'Big data' in healthcare encompass measurements collated from multiple sources with various degrees of data quality. These data require quality control assessment to optimise quality for clinical management and for robust large-scale data analysis in healthcare research. Height and weight data represent one of the most abundantly recorded health statistics. The shift to electronic recording of anthropometric measurements in electronic healthcare records, has rapidly inflated the number of measurements. WHO guidelines inform removal of population-based extreme outliers but an absence of tools limits cleaning of longitudinal anthropometric measurements. We developed and optimised a protocol for cleaning paediatric height and weight data that incorporates outlier detection using robust linear regression methodology using a manually curated set of 6,279 patients' longitudinal measurements. The protocol was then applied to a cohort of 200,000 patient records collected from 60,000 paediatric patients attending a regional teaching hospital in South England. WHO guidelines detected biologically implausible data in &lt;1% of records. Additional error rates of 3% and 0.2% for height and weight respectively were detected using the protocol. Inflated error rates for height measurements were largely due to small but physiologically implausible decreases in height. Lowest error rates were observed when data was measured and digitally recorded by staff routinely required to do so. The protocol successfully automates the parsing of implausible and poor quality height and weight data from a voluminous longitudinal dataset and standardises the quality assessment of data for clinical and research applications.</p

SARS-CoV-2 Viral load at presentation to hospital is independently associated with the risk of death

Objectives Previous studies have suggested that SARS-CoV-2 viral load, measured on upper respiratory tract samples at presentation to hospital using PCR Cycle threshold (Ct) value, has prognostic utility. However, these studies have not comprehensively adjusted for factors known to be intimately related to viral load. We aimed to evaluate the association between Ct value at admission and patient outcome whilst adjusting carefully for covariates. Methods We evaluated the association between Ct value at presentation and the outcomes of ICU admission and death, in patients hospitalised during the first wave of the pandemic in Southampton, UK. We adjusted for covariates including age, duration of illness and antibody sero-status, measured by neutralisation assay. Results 185 patients were analysed, with a median [IQR] Ct value of 27.9 [22.6–32.1]. On univariate analysis the Ct value at presentation was associated with the risk of both ICU admission and death. In addition, Ct value significantly differed according to age, the duration of illness at presentation and antibody sero-status. On multivariate analysis, Ct value was independently associated with risk of death (aOR 0.84, 95% CI 0.72–0.96; p = 0.011) but not ICU admission (aOR 1.04, 95% CI 0.93–1.16; p = 0.507). Neutralising antibody status at presentation was not associated with mortality or ICU admission (aOR 10.62, 95% CI 0.47–889; p = 0.199 and aOR 0.46, 95% CI 0.10–2.00; p = 0.302, respectively). Conclusions SARS-CoV-2 Ct value on admission to hospital was independently associated with mortality, when comprehensively adjusting for other factors and could be used for risk stratification.</p

Routine molecular point-of-care testing for SARS-CoV-2 reduces hospital-acquired COVID-19

Objectives: Risk of hospital-acquired COVID-19 (HA-COVID-19) infection is increased by cohorting infected and non-infected patients together in assessment areas, whist awaiting laboratory PCR results. Molecular point-of-care tests (mPOCT) reduce time to results and improve patient flow but the impact on HA-COVID-19 is unknown. Methods: In this pre and post implementation study patients were evaluated across two time periods: March 1st to August 13th 2020, prior to the introduction of mPOCT in medical admissions areas, and 14th August 2020 to 1st April 2021, after mPOCT introduction. The primary outcome was proportion of HA-COVID-19 infection among all COVID-19 positive patients. Secondary outcome measures included time to SARS-CoV-2 results, length of time spent in the medical assessment area and comparison of local, regional and national proportions of HA-COVID-19. Results: 1988 patients were admitted through the acute medicine admission cohorting area and tested for SARS-CoV-2 prior to introducing mPOCT and 4640 afterwards. Median (IQR) time to SARS-CoV-2 result was 6.5 (2.1–17.9) hours prior to introducing mPOCT and 1.0 (0.8–1.3) hours afterwards (p &lt; 0.0001). Median (IQR) duration in the assessment cohort area was 12.0 (4.8–20.6) hours prior to introduction of POCT and 3.2 (2.0–5.6) hours afterwards (p &lt; 0.0001). The proportion of hospital-acquired COVID-19 cases was 108 (16.5%) of 654 prior to introducing mPOCT compared with 168 (9.4%) of 1782 afterwards, (HR 0.55, 95%CI 0.43–0.70; p &lt; 0.0001). In the period following the introduction of mPOCT up to 1st April 2021 the median proportion of HA-COVID-19 was 13.6% (95%CI 8.2–18.9%) locally, compared with 43.8% (95%CI 37.8–49.9%) for all acute NHS trusts regionally and 30.9% (95%CI 28.4–33.5%) for all NHS trusts nationally. Conclusions: Routine mPOCT for SARS-CoV-2 was associated with reduced time to results, time spent in admission cohort areas, and hospital-acquired COVID-19, compared to laboratory PCR.</p

Routine, molecular point-of-care testing for SARS-CoV-2 and other respiratory viruses within an acute oncology service improves patient care

Objectives: COVID-19 has caused significant challenges for infection prevention measures and patient flow in hospital admission pathways. We aimed to assess the impact of replacing laboratory PCR with molecular point-of-care testing (mPOCT) for respiratory viruses including SARS-CoV2, within an Acute Oncology Service (AOS).  Methods: this pre- and post-implementation study took place in the AOS of a large teaching hospital, in Southampton, UK. We collected data from two periods: November 25th 2019 to November 24th 2020, when respiratory virus testing utilised laboratory PCR and December 1st 2020 to May 31st 2021 following the introduction of mPOCT. The primary outcome was the time to results.  Results: 2189 patients were tested in the pre-implementation period and 1540 in the post-implementation period. Median (IQR) time to results was 5.8 hours (4.2-10.6) pre-implementation and 1.9 hours (1.5-3.0) post-implementation (difference -3.6h [95%CI to -3.8 to -3.5]; p&lt;0.0001). Median time spent in assessment areas was 6.0 hours (4.1-7.9) pre-implementation and 5.5 hours (3.8-7.4) post-implementation (p&lt;0.0001). 20 (0.9%) patients admitted via AOS assessment unit developed hospital-acquired respiratory virus infection pre-implementation versus 0 (0%) post-implementation (p=0.031).  Conclusions: routine mPOCT for respiratory viruses, including SARS-CoV-2, was associated with a reduced time to results, reduced time in assessment areas, and a reduction in the rates of hospital-acquired respiratory virus infection in an acute oncology assessment uni

Emergency Department point-of-care antiviral host response testing is accurate during periods of multiple respiratory virus co-circulation

Objectives: FebriDx is a CE-marked, FDA-approved point-of-care test that detects the antiviral host response protein Myxovirus Resistance Protein A (MxA), in addition to C-reactive protein, using finger-prick blood. FebriDx MxA detection had a high negative predictive value for COVID-19 in symptomatic adults presenting to hospital in the first waves of the pandemic and was used subsequently as a ‘rule out’ triage tool in Emergency departments. The diagnostic accuracy of FebriDx MxA in the current context of co-circulation of influenza, SARS-CoV-2, and Respiratory Syncytial Virus (RSV), and in the era of COVID-19 vaccination, is unknown.Methods: we retrospectively evaluated the diagnostic performance of FebriDx MxA in adults with acute respiratory symptoms presenting to the Emergency Department (ED) of a large UK teaching hospital using Reverse Transcription Polymerase Chain Reaction (RT-PCR) as the reference standard (Cepheid Xpert Xpress SARS-CoV-2/Flu/RSV). Results: between March 9th 2022 and March 8th 2023, 5426 patients had both FebriDx and RT-PCR testing with valid results. 999 (18.4%) of patients had influenza detected, 520 (9.6%) SARS-CoV-2, and 190 (3.5%) RSV. Negative Predictive Value (NPV) of MxA detection by FebriDx was 97.5% (96.9-98.0) for influenza, 97.1% (96.4-97.7) for SARS-CoV-2, 98.1% (97.5-98.6) for RSV, and 92.8% (91.8-93.7) for all viruses combined.Conclusions: in symptomatic adults FebriDx MxA had a high NPV for influenza and RSV, and retained a high NPV for SARS-CoV-2, in the context of virus co-circulation and widespread COVID-19 vaccination. FebriDx continues to be a useful ‘rule out’ triage tool in the ED and could potentially be scaled to provide a national triage solution for future viral pandemics