Inpatient Teledermatology Referrals During the COVID-19 Pandemic in a UK Trust: A Comparative Review and Doctor Survey

Background The COVID-19 pandemic has broadened the scope of teledermatology services in the United Kingdom from a primarily outpatient-based triage tool to the management of inpatient referrals. In order to reduce the risk of transmission in hospital, a number of changes were implemented within our department. As part of this, our on-call referrals were transferred to a telemedicine app, which incorporates the secure transfer of user-generated patient images onto a web-based image management system providing remote access for the dermatology team. Objective This study aimed to compare how the introduction of this referral method impacted the nature and number of referrals received, the efficiency of the on-call service, and user preferences. Methods A retrospective cohort study was conducted to compare the number of referrals, time taken to review, and referral diagnoses between previous referral methods to the dermatology department (bleep, fax, email) (July and September 2019) and the new teledermatology app (July and September 2020). We also performed a survey of junior doctors, seeking their feedback and preferences pertaining to the new referral system. Results The number of referrals increased by 80%, with a 6-fold increase in lesion referrals. There is a possibility that not all referrals from 2019 were accounted for as paper documents are easily lost or discarded, highlighting another advantage of teledermatology in providing a reliable record of referrals. Dermatology referrals may have increased as the telemedicine app is more accessible to staff across sites. The telemedicine app also led to a reduction in time to review by 0.53 days, resulting in a significantly higher number of patients being given dermatology input on the day of the referral (78% vs 58%). This will have led to earlier treatment, improved patient outcomes, and shorter inpatient stays, resulting in potential cost reductions for the hospital. The survey of junior doctors showed that 81% preferred teledermatology to the previous referral methods. Conclusions The introduction of teledermatology has provided an effective and acceptable method of managing on-call dermatology referrals. Easier access to dermatology advice via teledermatology may result in higher numbers of referrals, which may warrant strict referral criteria to prevent oversubscription of the on-call service. Teledermatology ensures an accurate log of referrals, including the nature of referrals, allowing for better auditing and service improvement. Teledermatology referrals allow for advice to be provided within shorter time frames compared to previous methods. This should improve patient outcomes and reduce hospital admission stays, potentially resulting in cost savings for the hospital. Conflict of Interest None declared.

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Inpatient Teledermatology Referrals During the COVID-19 Pandemic in a UK Trust: A Comparative Review and Doctor Survey (Preprint)

10.2196/preprints.35388 ◽

2021 ◽

Author(s):

Lucy Howard ◽

O Jagun ◽

A Hong ◽

Z Hassan ◽

C Wong ◽

...

Keyword(s):

Patient Outcomes ◽

Fold Increase ◽

User Preferences ◽

Remote Access ◽

Service Improvement ◽

Junior Doctors ◽

Potential Cost ◽

Dermatology Department ◽

Number Of Patients ◽

Comparative Review

BACKGROUND The COVID-19 pandemic has broadened the scope of teledermatology services in the United Kingdom from a primarily outpatient-based triage tool to the management of inpatient referrals. In order to reduce the risk of transmission in hospital, a number of changes were implemented within our department. As part of this, our on-call referrals were transferred to a telemedicine app, which incorporates the secure transfer of user-generated patient images onto a web-based image management system providing remote access for the dermatology team. OBJECTIVE This study aimed to compare how the introduction of this referral method impacted the nature and number of referrals received, the efficiency of the on-call service, and user preferences. METHODS A retrospective cohort study was conducted to compare the number of referrals, time taken to review, and referral diagnoses between previous referral methods to the dermatology department (bleep, fax, email) (July and September 2019) and the new teledermatology app (July and September 2020). We also performed a survey of junior doctors, seeking their feedback and preferences pertaining to the new referral system. RESULTS The number of referrals increased by 80%, with a 6-fold increase in lesion referrals. There is a possibility that not all referrals from 2019 were accounted for as paper documents are easily lost or discarded, highlighting another advantage of teledermatology in providing a reliable record of referrals. Dermatology referrals may have increased as the telemedicine app is more accessible to staff across sites. The telemedicine app also led to a reduction in time to review by 0.53 days, resulting in a significantly higher number of patients being given dermatology input on the day of the referral (78% vs 58%). This will have led to earlier treatment, improved patient outcomes, and shorter inpatient stays, resulting in potential cost reductions for the hospital. The survey of junior doctors showed that 81% preferred teledermatology to the previous referral methods. CONCLUSIONS The introduction of teledermatology has provided an effective and acceptable method of managing on-call dermatology referrals. Easier access to dermatology advice via teledermatology may result in higher numbers of referrals, which may warrant strict referral criteria to prevent oversubscription of the on-call service. Teledermatology ensures an accurate log of referrals, including the nature of referrals, allowing for better auditing and service improvement. Teledermatology referrals allow for advice to be provided within shorter time frames compared to previous methods. This should improve patient outcomes and reduce hospital admission stays, potentially resulting in cost savings for the hospital.

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67 The Evolution of A Frailty Service

Age and Ageing ◽

10.1093/ageing/afab030.28 ◽

2021 ◽

Vol 50 (Supplement_1) ◽

pp. i12-i42

Author(s):

C Abbott ◽

K Bishop ◽

F Hill ◽

C Finlow ◽

R Maraj

Keyword(s):

Cost Effectiveness ◽

Patient Outcomes ◽

Local Population ◽

Management Team ◽

Pdsa Cycle ◽

North Wales ◽

Number Of Patients ◽

Constant State ◽

Clinical Resource ◽

Improve Patient

Abstract Introduction In September 2017 our frailty service was started within our medium sized DGH in North Wales. Working with our management team we secured a significant clinical resource including: We describe how resources, setting and staffing develop over a 2 year period in order to create a service which meets the needs of the local population. Method The service has been in a constant state of development since it has been in operation, utilising a PDSA model with regular meetings of clinical and managerial staff to analyse performance. Results With each new PDSA cycle the amount of patients reviewed has increased. With the move to AMU we increased the monthly number of patients reviewed from 29 to 172 patients reviewed, 97 of which were discharged directly from the unit. Conclusion Using QI methodology our Frailty Service has improved dramatically since its inception. We will continue to analyse how we work to improve patient outcomes and cost effectiveness.

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1186. Cefazolin inoculum effect predicts reduced susceptibility to other antibiotics and patient outcomes in MSSA endovascular infections

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.1372 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S617-S617

Author(s):

Dan Smelter ◽

Sue McCrone ◽

Warren Rose

Keyword(s):

Infective Endocarditis ◽

Mortality Rate ◽

Patient Outcomes ◽

Treatment Options ◽

Fold Increase ◽

Specific Mechanism ◽

Research Support ◽

High Burden ◽

Low Toxicity ◽

Inoculum Effect

Abstract Background MSSA Infective endocarditis (IE) is inherently a high-burden infection with up to a 30% mortality rate. Cefazolin is an appealing treatment option for IE with low toxicity and a favorable dosing scheme. However, cefazolin has been associated with treatment failure in IE, attributed to an inoculum effect. The specific mechanism underlying the cefazolin inoculum effect (CIE) remains undetermined, but CIE has been linked to both blaZ expression and agr dysfunction. This study aims to determine whether CIE is linked to reduced susceptibility to other antibiotics and worse outcomes regardless of therapy in MSSA endovascular infections. Methods Sixty-four MSSA strains were collected from patients with endovascular infections not treated with cefazolin. To determine CIE phenotype, strains were cultured and MICs assayed for cefazolin, nafcillin, and vancomycin at 107 CFU/mL for high-inocula (HI) and 105 CFU/mL for standard-inocula (SI). This study defined CIE as a ≥ 4-fold increase in MIC at HI compared to SI, with at least an MIC of 4 mg/L at HI. Nitrocefin disks identified blaZ expression, and beta lysin disks were used to determine hemolysin type and agr function. Patient outcomes of mortality and bacteremia duration were assessed across cohorts. Results Twenty-four strains exhibit a CIE (38%), with 10 strains having an MIC of ≥ 32mg/L at HI. Nafcillin and vancomycin also had an inoculum effect, uncoupled from the CIE and occurring at a lower frequency and amplitude at HI. Presence of CIE had a greater association with blaZ expression (71% vs 25%) than agr dysfunction (38% vs 20%). 50% (9/18) of CIE infections were cleared within 48 hours while 77% (20/26) of CIE-negative infections were cleared within 48 hours (P=0.106). However, presence of CIE was not associated with increased mortality (25% CIE-positive vs 35%; P=0.578) Conclusion Previous studies for CIE failed to enrich for isolates from endovascular sources, where inocula are known to be high. This study presents one of the largest endovascular source cohorts for CIE evaluation. It identifies that CIE prevalence (38%) is higher than reports from diverse infection sources (10-36%). CIE appears to predict bacteremia duration with other MSSA treatment options, suggesting mechanisms independent of blaZ and agr function for this phenomenon. Disclosures Warren Rose, PharmD, MPH, Merck (Grant/Research Support)Paratek (Grant/Research Support)

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Developing junior doctors as leaders of service improvement

Leadership in Health Services ◽

10.1108/lhs-04-2014-0037 ◽

2014 ◽

Vol 27 (4) ◽

pp. 316-329 ◽

Cited By ~ 6

Author(s):

Jason Micallef ◽

Brodene Straw

Keyword(s):

Leadership Development ◽

Medical Staff ◽

Medical Service ◽

Health Service Delivery ◽

Public Healthcare ◽

Service Improvement ◽

Junior Doctors ◽

Program Outcomes ◽

Improvement Program ◽

Content Type

Purpose – This paper aims to provide an overview of the design and initial outcomes of a leadership and service improvement program for junior medical staff. Design/methodology/approach – This paper describes the rationale, initial set-up, structure, program outcomes and future directions of the Medical Service Improvement Program for junior doctors. This program is a recent initiative of the Western Australian public healthcare system. Findings – The Medical Service Improvement Program illustrates a successful approach to developing junior doctors to lead improvements in health service delivery. The program has resulted in tangible personal outcomes for participants, in addition to important organisational outcomes. Practical implications – This paper provides an evidence-based structured approach to developing the leadership abilities of junior medical staff. It provides practical information on the design of the leadership program that aligns the participant learning outcomes to postgraduate medical competencies. The program has demonstrated clear service outcomes, confirming that junior medical staff is both capable and committed to leading service improvement and reform. Originality/value – This paper provides clear evidence for the benefits of providing dedicated non-clinical time for junior medical staff to lead quality and improvement initiatives. This case study will assist hospital administrators, postgraduate education units and those involved in designing and administering clinical leadership development programs.

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CLINICAL PROFILE OF OUTPATIENTS ATTENDING DERMATOLOGY DEPARTMENT DURING COVID-19 LOCKDOWN RELAXATION PERIOD IN A TERTIARY CARE CENTRE IN SOUTH INDIA – A CROSS-SECTIONAL ANALYTICAL STUDY

10.36106/ijsr/6906051 ◽

2021 ◽

pp. 13-16

Author(s):

Afthab Jameela Wahab ◽

Pavithra Gunasekaran ◽

P. Mohan ◽

V. Sudha ◽

L. Balamurugan ◽

...

Keyword(s):

South India ◽

Tertiary Care ◽

Care Centre ◽

Tertiary Care Centre ◽

Dermatology Department ◽

Cutaneous Manifestations ◽

Relaxation Period ◽

Number Of Patients ◽

Outpatient Practice ◽

The Impact

Background - The cutaneous manifestations of the novel coronavirus have been well documented. However, there are few studies that relate to the clinical prole of regular dermatology outpatients seeking treatment during the lockdown relaxation period braving the pandemic. With the Aim - view to determine the changes seen in dermatology outpatient practice, this study analysed the clinical prole of new patients attending the Dermatology Outpatient Department (OPD) during the COVID-19 lockdown relaxation period in a tertiary care centre in a metropolitan suburb in South India. New dermatology outpatients during the months of May, June, July and August Method - 2020 were included in the study. Outpatient data for this period was analysed and compared with corresponding data for the same period in the previous two years. There was a Result – decrease in the OP census, number of patients in the extremes of life as well as those with asymptomatic dermatoses. There was an increase in the number of patients with infections, particularly dermatophytosis. There was also a noteworthy absence of dermatological emergencies. Conclusion - In essence, our study shows the impact of COVID-19 pandemic on the routine dermatology outpatient services with signicant changes in the clinical prole of outpatient practice following lockdown relaxation.

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Abstract 2524: Increasing the Proportion of Patients Treated with Stroke Thrombolysis: Reducing In-hospital Delays has Substantially More Impact than Extension of the Time Window

Stroke ◽

10.1161/str.43.suppl_1.a2524 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Martin A James ◽

Thomas Monks ◽

Ken Stein ◽

Martin Pitt

Keyword(s):

Time Window ◽

Discrete Event ◽

Fold Increase ◽

Service Improvement ◽

Disability Benefit ◽

Prospective Data ◽

Stroke Service ◽

Event Simulation ◽

Simulation Based ◽

The Impact

Background Pooled analyses show the benefit of IV alteplase for ischemic stroke up to 4·5 hours after onset, and expert guidelines have been updated to reflect this. However, the benefit from thrombolysis is critically time-dependent, and the additional benefit from extending the time window may be jeopardised by in-hospital delays. Methods We developed a discrete-event simulation based on prospective data from 1142 acute stroke patients arriving at our large district hospital over a two-year period to April 2011, modelling the time spent in the ED for triage and assessment, brain imaging and, if applicable, thrombolysis. Outputs from the model included arrival to treatment times (ATT), percentage of strokes thrombolysed, and the number of thrombolysed patients with a 90 day modified Rankin Scale (mRS) of 0-1. We sought to model the current stroke pathway (treatment <3 hours of onset), and compare it with developmental scenarios exploring the impact of extending treatment from 3 to 4.5 hours, of ED staff alerting the stroke service at triage, of ambulance pre-alert to the stroke service, and combinations of these measures. Results The model illustrates that extending the treatment window modestly increases the percentage of acute strokes thrombolysed, from 5% to 6% (95% CI 5.8-6.1%), and increases the number of thrombolysed patients with mRS 0-1 by 7 per year (95% CI 5.9-8.0). Both the triage alert and ambulance pre-alert scenarios increase thrombolysis rates to 15% (95% CI 14.9% to 15.7%); but the ambulance pre-alert reduces ATT by a mean of 27 mins (95% CI 26.3-28.4) compared to the triage alert scenario. The ambulance pre-alert scenario increases the number of thrombolysed patients with mRS 0-1 by 35/year (95% CI 32.9-37.7) compared to 22 (95% CI 20.4-23.5) in the triage alert scenario. Combining the treatment extension with either alerting measure does not increase the thrombolysis rate further (15%, 95% CI 14.7-15.1%). Sensitivity analysis illustrates that the pre-alert system is the least vulnerable to a drop in compliance rates. Conclusions Our simulation model shows that the greatest disability benefit accrues from measures to substantially reduce in-hospital delays to alteplase treatment - a potential three-fold increase in the proportion of patients treated. Compared to extending the time window for alteplase from 3 to 4.5 hours, eradicating in-hospital delays to treatment offers a five-fold greater disability benefit, and this should be the pre-eminent focus of service improvement for all emergency receiving hospitals.

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720. Efficacy of Fosfomycin for Injection (FOS) vs. Piperacillin–Tazobactam (PIP-TAZ) in Adults with Complicated Urinary Tract Infection (cUTI) and Acute Pyelonephritis (AP): ZEUS Study Outcomes in Patients With Reduced Study Drug Susceptibility

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.788 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S324-S324

Author(s):

Keith S Kaye ◽

Anita F Das ◽

Paul B Eckburg ◽

Steven P Gelone ◽

Jennifer Schranz ◽

...

Keyword(s):

Clinical Cure ◽

Complicated Urinary Tract Infection ◽

Study Drug ◽

Fold Increase ◽

The United States ◽

Drug Susceptibility ◽

Number Of Patients ◽

Intent To Treat ◽

Almost All

Abstract Background FOS is being pursued for US registration in cUTI/AP. Safety and efficacy of FOS vs. PIP-TAZ were demonstrated in the noninferiority ZEUS trial in hospitalized patients with cUTI/AP. Although FOS resistance has been observed in several in vitro studies, resistance rates in clinical settings have remained relatively stable despite >40 years of clinical use of FOS outside of the United States. Here we report outcomes in patients who developed reduced susceptibility to study drug (FOS or PIP-TAZ) after enrollment in ZEUS. Methods Patients received IV FOS 6g q8h or PIP-TAZ 4.5g q8h for 7 days (no oral switch allowed). The primary endpoint was overall success (clinical cure + microbiologic eradication) in microbiologic modified intent-to-treat (m-MITT) population at test-of-cure (TOC; Day 19–21). Reduced susceptibility to FOS or PIP-TAZ was defined as a ≥4-fold increase from baseline in minimum inhibitory concentration (MIC) at Day 5, end of treatment (EOT; Day 7–8), TOC, or late follow-up (LFU; Day 26 ± 2). Microbiologic eradication/persistence of baseline and postbaseline pathogens was confirmed post hoc by pulsed-field gel electrophoresis (PFGE). Results In all m-MITT patients, overall success/clinical cure/microbiologic eradication rates (with PFGE) at TOC were 69.0/90.8/70.7% (FOS) and 57.3/91.6/60.1% (PIP-TAZ). Reduced study drug susceptibility was identified in 7/184 (3.8%) FOS and 8/178 (4.5%) PIP-TAZ patients; all had monomicrobial infections (Table 1). Of these patients, almost all were aged ≥50 years (93%), male (73%), white (100%), and had a screening diagnosis of cUTI (93%). At TOC, 7/7 FOS patients and 7/8 PIP-TAZ patients had microbiologic persistence but all patients were clinical cures; these responses were all sustained through LFU (Table 1). Conclusion In the ZEUS study, few patients had urine isolates with reduced postbaseline susceptibility to either FOS or PIP-TAZ. No trend was observed in isolate species associated with decreased susceptibility to FOS or PIP-TAZ, including various Enterobacteriaceae species and Pseudomonas aeruginosa. Despite microbiologic persistence at TOC in a small number of patients, all of these patients were clinical cures at TOC and sustained cures at LFU. Disclosures All authors: No reported disclosures.

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“Epizoonosis of Dermatophytosis”: A Clinico - Mycological Study of Dermatophytic Infections in Central Nepal

Kathmandu University Medical Journal ◽

10.3126/kumj.v10i1.6910 ◽

2012 ◽

Vol 10 (1) ◽

pp. 20-23 ◽

Cited By ~ 1

Author(s):

M Mathur ◽

SK Kedia ◽

RBK Ghimire

Keyword(s):

Fungal Species ◽

Tinea Corporis ◽

Female Dominance ◽

Trichophyton Verrucosum ◽

Dermatology Department ◽

Direct Microscopy ◽

Male Predominance ◽

Central Nepal ◽

Clinical Type ◽

Number Of Patients

Background Identification of dermatophytic species in clinical settings are important not only for epidemiological but also for the treatment. Objectives Present study was carried out to find out the clinical variants of Dermatophytosis and species of fungus responsible for the disease. Methods The prospective observational analysis of 200 clinically suspected cases of dermatophytic infection attending Dermatology department of College of Medical Sciences Teaching Hospital, Bharatpur, Chitwan, Nepal. Skin scraping, hair and nail samples were collected and processed according to standard protocol. Results Maximum number of patients enrolled in study were reported for treatment 5-8 weeks after the onset of disease. Overall male predominance was observed and ages between 26-30 years. Tinea corporis was the most common clinical type of tinea with female dominance in our study. 10 % of cases were having extensive Tinea. 71.5% of samples were positive on direct microscopy and 62 % positive on culture. Samples from T capitis were highest positive by direct microscopy (80%) and over all dominant species of fungus isolated in our study was Trichophyton verrucosum (30.6%). Conclusions The study highlighted Tinea corporis as the most common clinical type with female predominance. Overall predominant causative fungal species isolated was Trichophyton verrucosum. KATHMANDU UNIVERSITY MEDICAL JOURNAL VOL.10 | NO. 1 | ISSUE 37 | JAN - MAR 2012 | 30-33DOI: http://dx.doi.org/10.3126/kumj.v10i1.6910

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Clinical engagement: a new concept or common sense all round?

Australian Health Review ◽

10.1071/ah18010 ◽

2019 ◽

Vol 43 (4) ◽

pp. 392

Author(s):

Stephen Bolsin ◽

Jenny Carter ◽

Aileen Kitson ◽

Donna Walter ◽

Stephen Roberts

Keyword(s):

Patient Outcomes ◽

Common Sense ◽

Employee Satisfaction ◽

Clinical Governance ◽

Healthcare Organisation ◽

Number Of Patients ◽

Clinical Engagement ◽

To Receive ◽

Professional Disciplines

Clinical engagement has supplemented clinical governance in healthcare to strengthen the contribution of medical professionals to the assessment of clinical outcomes for patients. Assessments of clinical engagement have, until now, been qualitative; this case study introduces the concept of quantitative assessment of clinical engagement by measuring the number of patients managed according to specialist society guidelines. Such an assessment engages all staff (medical, nursing, allied health and pharmacy) involved in patients receiving treatment according to such guidelines and provides an assessment of individual and organisational compliance with those guidelines. Clinical engagement is then quantified as the percentage of patients that have been documented to receive specialist society- or college-approved guideline-compliant treatment, relative to the total number who could receive such treatment, in any healthcare organisation. What is known about the topic? Clinical engagement has emerged in recent years as a virtue to be encouraged in healthcare organisations because of its association with improved patient outcomes and employee satisfaction. Assessments have relied on repeated staff surveys in order to gauge engagement. What does this paper add? This paper proposes a novel means of measuring clinical engagement in an organisational setting. The vision put forward is that adherence to clinical guidelines in an organisation measures clinician engagement across professional disciplines. What are the implications for practitioners? The implications are that organisations will contribute to measuring the adherence of specialty groups of clinicians to guidelines that the clinicians select and use the data for individual and organisational accreditation.

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Increasing Trends in Opioid Use From 2010 to 2018 in the Region of Valencia, Spain: A Real-World, Population-Based Study

Frontiers in Pharmacology ◽

10.3389/fphar.2020.612556 ◽

2020 ◽

Vol 11 ◽

Author(s):

Isabel Hurtado ◽

Aníbal García-Sempere ◽

Salvador Peiró ◽

Gabriel Sanfélix-Gimeno

Keyword(s):

Health And Safety ◽

Fold Increase ◽

The United States ◽

Population Based ◽

Annual Number ◽

World Population ◽

Opioid Use ◽

Cross Sectional ◽

Opioid Prescription ◽

Number Of Patients

Background: The opioid epidemic has been extensively documented in the United States and Canada, but fewer data are available for Europe.Aim: To describe the trends in opioid use—volume of prescriptions, dosage and number of patients treated—in a Spanish population with more than 4.2 million inhabitants aged 18 years and older.Patients and Methods: Population-based cross-sectional analysis of opioid prescription in adults (≥18 years) from January 1, 2010 to December 31, 2018 in the region of Valencia, Spain. Outcomes were estimated on an annual basis: number of prescriptions, prescription rate per 100 inhabitants, dosage per capita (morphine mg equivalents, MME/c) and volume of patients treated (overall and by drug).Results: Over the study period, 2,107,756 unique patients were prescribed more than 35 million total treatments. The yearly number of treatments doubled, and total MME/c showed almost a threefold increase. Fentanyl MME/c more than tripled, accounting for 34.4% of the total MME/c in 2018. Oxycodone MME/c showed a 10-fold increase, while tapentadol, launched in 2011, showed the highest growth rates. The annual number of patients receiving at least one opioid prescription more than doubled, from 335,379 in 2010 to 722,838 in 2018.Conclusions: Even if proportions still seem far from epidemic, urgent research is warranted on the observed patterns of use, their appropriateness and their association with health and safety outcomes, especially for high-use and high-strength drugs.

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