Advance Directive Initiative- St. Johnsbury, VT

Valuable time is frequently lost during end of life care or in the unforeseen circumstance of severe injury or illness when a patient does not have appropriate advance care planning. While end of life care costs continue to increase in an aging U.S. population, only 26% of U.S. healthcare consumers have completed Advance Directives (ADs). One of the key barriers to increased participation and awareness continues to be lack of patient education. Due to the complicated terminology often used in these legal documents, one essential component of the AD initiative at St. Johnsbury Community Health Center is creating a simple and effective handout to improve patient education.https://scholarworks.uvm.edu/fmclerk/1335/thumbnail.jp

Public Awareness of Medical Imaging as a Source of Ionizing Radiation Exposure

Background. Biological effects of exposure to ionizing radiation (IR) are well known. Literature suggests most patients and physicians lack proficient understanding of risks associated with ionizing radiation. Our study goals were to: assess the extent to which productive, informed conversations regarding ionizing radiation are occurring between patients and providers; characterize public awareness of medical imaging procedures as sources of IR exposure; and investigate best practices in patientprovider communications. Methods. We developed and administered a 17-question survey to 303 adults at five locations across Chittenden County, Vermont, over a 6-week period in fall 2016. Descriptive and statistical analyses were conducted using SPSS. Results. The three age groups of respondents had different knowledge levels about ionizing radiation (p Conclusions/Recommendations. 1. A standard oral presentation for pre-imaging patient-provider communication, along with a written handout, be developed; 2. A section of the electronic medical record (also accessible through the patient portal) containing IR exposure be created for patients and physicians to track individuals\u27 information.https://scholarworks.uvm.edu/comphp_gallery/1249/thumbnail.jp

Implementation of Food Insecurity Screening in Adult Primary Care Patients

Background Social determinants of health (SDH) are increasingly recognized for their importance in driving health outcomes. Food insecurity (FI), a lack of regular access to adequate food, is prevalent in the United States, impacting an estimated 12% of households in 2017. The two-item Hunger Vital Sign (HVS), has demonstrated validity in identifying FI, though there is not agreement on how best to address FI in a healthcare setting. This study aimed to evaluate the implementation of a screening protocol for FI in adult primary care patients, and to investigate any downstream impacts on services delivered in patients who screened positive for FI. Methods In December 2017, our institution added functionality for entering and tracking SDH via an Epic-based EMR. The tool, which incorporated the HVS, was developed based on the Health Related Social Needs Screening Tool by CMS. We instituted protocols for administering and entering the HVS component at two academic primary care sites in Vermont: a semi-urban adult internal medicine practice and a rural family medicine practice. Implementation plans were developed at both sites, each involving education for providers and staff, and pairing of the HVS with annual behavioral health screening. We then identified patients who screened positive for FI from January 1 through April 30, 2018 and retrospectively analyzed charts for services in place prior to positive screens, as well as for documentation and actions taken in response to positive screens. Results A total of 1,188 patients were screened for FI during the study period, and 79 (7%) screened positive. Of patients with FI, 41 (48%) had some documentation of food or financial insecurity prior to screening. A total of 32 (37%) were documented to have prior access to food insecurity services such as food stamps, food bank etc., and 19 (22%) had been previously seen by a social worker embedded in the practice. At the time of positive screen, 26 (31%) provider notes included documentation of FI. In response to a positive screen, 16 patients (19%) were offered social work referral, of whom 12 (14%) completed a visit. Conclusions In this brief pilot study, we found the implementation of a process for FI screening in primary care to be relatively straightforward, made so by pairing it with other annual health screening protocols and the presence of a function for entering SDH in Epic. The HVS screening tool was also successful in newly identifying FI, as evidenced by the absence of prior documentation in nearly half of food insecure patients. However, the paucity of subsequent documentation and the small fraction of patients who received targeted intervention, despite the education for providers and staff at both practices, indicate a need for further investigation around the best approach to addressing FI in a primary care setting, once it is identified

Surgical site infection after gastrointestinal surgery in children : an international, multicentre, prospective cohort study

Introduction Surgical site infection (SSI) is one of the most common healthcare-associated infections (HAIs). However, there is a lack of data available about SSI in children worldwide, especially from low-income and middle-income countries. This study aimed to estimate the incidence of SSI in children and associations between SSI and morbidity across human development settings. Methods A multicentre, international, prospective, validated cohort study of children aged under 16 years undergoing clean-contaminated, contaminated or dirty gastrointestinal surgery. Any hospital in the world providing paediatric surgery was eligible to contribute data between January and July 2016. The primary outcome was the incidence of SSI by 30 days. Relationships between explanatory variables and SSI were examined using multilevel logistic regression. Countries were stratified into high development, middle development and low development groups using the United Nations Human Development Index (HDI). Results Of 1159 children across 181 hospitals in 51 countries, 523 (45 center dot 1%) children were from high HDI, 397 (34 center dot 2%) from middle HDI and 239 (20 center dot 6%) from low HDI countries. The 30-day SSI rate was 6.3% (33/523) in high HDI, 12 center dot 8% (51/397) in middle HDI and 24 center dot 7% (59/239) in low HDI countries. SSI was associated with higher incidence of 30-day mortality, intervention, organ-space infection and other HAIs, with the highest rates seen in low HDI countries. Median length of stay in patients who had an SSI was longer (7.0 days), compared with 3.0 days in patients who did not have an SSI. Use of laparoscopy was associated with significantly lower SSI rates, even after accounting for HDI. Conclusion The odds of SSI in children is nearly four times greater in low HDI compared with high HDI countries. Policies to reduce SSI should be prioritised as part of the wider global agenda.Peer reviewe