Oral neglect as a marker of broader neglect: a cross-sectional investigation of orodental consultation letter of leukemic admitted patients in Iran

Background Leukemia is the main malignant hematologic disease of children with different oral manifestations and clinical features. Attention to the oral manifestations is essential for better management. This study assessed the oral and dental consultations conducted in the admitted leukemic patients of an Iranian teaching hospital. Methods In this descriptive cross-sectional study, medical records of patients admitted in Yazd Shahid Sadoughi Hospital were evaluated. Records of 300 patients with leukemia were randomly selected. Data including demographic information on age, sex, type of oral problems, prescribed instructions and leukemia type were extracted from archived records and registered on the checklist. Finally, Data were analyzed by SPSS17 using Chi-square test. Results The results showed the average age ± SD of patients were 24.36 ± 23.91 with a range of 4 days to 86 years. Among 300 files, 167 belonged to males (55.7%) and 133 pertained to females (44.3%). The most prevalent type of underlying disease was ALL (Acute lymphocytic leukemia) with the frequency of 180 persons (60%). Only 12 (4%) of patients were referred to a specialist due to oral problems. Of all cases of consultation requests, 75% received consultation because of dental problems and 25% for mucosal problems. There was a statistically significant difference between age and consultation request (P = 0.002). Conclusions According to the results of this study, orodental consultation request rate for admitted leukemic patients was low. Pediatric hematologist and oncologists to some extent had more interest to consult due to oral and dental problems rather than others.

Availability, timeliness, documentation and quality of consultations among hospital departments: a prospective, comparative study

Background Many in-patients require care from practitioners in various disciplines. Consultations most probably have significant implications for hospitalization outcomes. Purpose To determine key aspects of consultations provided by various departments to formulate an optimal policy. Methods This study comprised two methods: first, a questionnaire was completed in 2019 by 127 physicians interns, residents and senior doctors) from the medical and surgical departments (64 from the surgical wards, 43 from the medical wards and 22 from the emergency room and General ICU) regarding the availability, timeliness and documentation rate of the consultations they received from different disciplines. The investigators rounded through the various departments that were included in the study and they accosted a sample of interns, residents and attending physicians, who were then asked to fill the questionnaire. Overall compliance of filling the questionnaire was 95%. Residents accounted for 72% of the filled questionnaires, seniors and interns accounted for 15 and 13% respectively. Second, a convenience sample of 300 electronic records of hospitalized patients (135 from the surgical wards, 129 from the Medical wards and 36 from the emergency room and General ICU) of actually carried out consultations was reviewed for validated indicators of quality for both the consultation request and response. We used a 5-point Likert scale, ranging from poor (1) to superb (5), to grade the measured parameters. Results The availability, timeliness and documentation rate for medical consultations were 4 ± 0.9, 4.1 ± 0.9 and 4.3 ± 0.9 respectively, as compared with surgical consultations 3.2 ± 1.1, 3.4 ± 1.2 and 3.6 ± 1.2 respectively (P < 0.001). The mean time (in hours) from the consultation request till documentation (of the requested consultation) by consultants in the medical and surgical departments was 3.9 ± 5.9 and 10.0 ± 15.6, respectively (P < 0.001). The quality of requests of consultations from the medical and surgical departments was 3.4 ± 1.1 and 2.8 ± 1.2, respectively (P < 0.001). Two different models of consultations are employed: while each medical department adopts several departments for medical consultations, each day’s on-call surgeon provides all the hospital’s surgical consultations. Conclusion We detected significant differences in key aspects of consultations provided by the departments. The medical model of consultations, in which each medical department adopts several other wards to which it provides consulting services upon request, should probably be adopted as a major policy decision by hospitals directors to enhance inter-departmental consultations.

Clinical and Epidemiological Characterization of Neurological Consults: When a Neurological Evaluation Is Requested

Background and Objectives: Medical consultation by a specialist physician consists of an evaluation to review diagnosis and management of patients with some neurological conditions referred from other specialty wards. This mode of care delivery has gained relevance in the field of neurology and adequate training on it is valuable, allowing neurologists to provide state-of-the-art management to patients with neurological manifestations. The present study aimed to characterize neurology consults and to discuss the roles of the neurologist within a hospital setting. Methods: A prospective analysis of neurological consultations provided to inpatients of a university hospital in São Paulo, Brazil, was performed from September 2016 to September 2017. These patients were followed by the principal investigator, who was not involved in their care. Results: We evaluated data from 117 female and 106 male inpatients with a mean age of 53.8 ± 2.4. The medical specialties that most frequently requested neurological consultations were Internal Medicine (17%), Cardiology (11.2%) and Pulmonology (9.4%). The main reasons for a neurology consultation request were seizures (15.6%); decreased level of consciousness (8.9%) and confusion (7.1%). The most frequent diagnosis in patients receiving a neurology consult were stroke (10.2%); hypoxic-ischemic encephalopathy (5.3%) and sepsis (2.2%). Conclusion: Our findings show the growing importance of the role of neurologists within hospital settings as many medical conditions present with neurological manifestations and the significance of the neurohospitalist model of care.

S114. THE EFFICACY OF “URGENT CONSULTATION REQUEST”; PRELIMINARY ANALYSIS OF A REAL-WORLD APP (REMIDCARE) FOR EARLY PSYCHOSIS

Background Patients are clamming for more personalized and closer clinical attention (Bonet et al. 2018). To this end, we developed RemindCare app. The app conducts daily and weekly assessments and this information is used to prevent relapses, to improve the therapeutic alliance and it is automatically included at the electronic clinical record of the hospital. Moreover, patients can contact clinicians by an “Urgent Consultation Request” (UCR), which is answered by a phone call in a period of 24-48h. This app was introduced in clinical practice in October 2018. Since then, 81 patients met criteria for inclusion and 57/81 (71%) started using the app. The aim of this study is to analyze the efficacy of this UCR to determine if this function can improve the real-world treatment of patients with early psychosis. Methods RemindCare app, is offered as an extra-service to the usual psychiatric care of patients in an Early Psychosis Program (EPP) at the Clinic Hospital of Valencia, Spain (Bonet et al. 2019). No remuneration is offered to any patient or clinician to use the app. Data of 57 patients diagnosed with a psychotic disorder was analyzed: the 26.3% (15/57) used the UCR (UCR group) and the 73.7% (42/57) did not (Non-UCR group). Mean age of the sample was 31.5 (SD=9.3), 56.1% were male, 87.7% caucasian and 82.5% were single. Mean years of illness was 3.5 (SD=2.8), CGI mean 4.1 (SD=0.9), GAF mean 60.5 (SD=12.3) and PANSS mean 56.6 (SD=12.2). Results Mean of months using the app was 8.4 (SD=4.5), 38.6% (22/57) of patients used the app for more than a year (12–13 months) and mean of engagement was 84.3 (SD=18.9). No significant differences were found between UCR and Non-UCR group in terms of demographic and clinical characteristics. However, there was a difference between groups in terms of engagement to the app (χ2= 6.3, p=0.04). The 93.3% of the UCR group had a percentage of engagement to the app between 81–100% compared to the 66.7% in the Non-UCR group and the number of visits to the Urgent Care Units (UCU) was also higher in the UCR group (χ2= 4.4, p=0.03). Additionally, only the 13.3% (2/15) of patients used the UCR for a psychotic symptom′s aggravation, the 33.3% (3/15) used it to inform of anxiety symptoms and another 33.3% (3/15) to change the clinical appointment. Moreover, the 66.7% (4/6) of patients who attended to UCU had previously made an UCR and they went to the UCU before that period of 24-48h of clinical response ended. Finally, there were no differences in terms of hospital admissions (χ2= 1.1, p=0.3) and psychotic relapses (χ2= 0.08, p=0.8) between groups. However, patients who stopped using the app had more relapses than patients who continued using it (χ2= 15.3, p&lt;0.000). Discussion To our knowledge, this is the first e-Health intervention systematically introduced in clinical practice. Rates of acceptance and engagement are high (71%; 84.3%) and nearly 40% of the sample is using the app for more than a year. Mean of engagement with the app, was extremely high among patients who used the UCR (93.3%; engagement between 81–100%) and although this UCR service was the most required in our previous survey (Bonet et al. 2018), these preliminary results suggest ¡ that the use of this alarm is not related to psychotic relapse detection. However, patients who use RemindCare app had less relapses than the ones who discontinue its use, which highlights the efficacy of the app. This, along with the high engagement and the positive feedback received, suggests that an improvement in real-world treatment of patients with early psychosis may be found in upcoming analysis.

LO79: The impact of access block on consultation time in the emergency department

Introduction: Access block (AB) is the most important indicator of Emergency Department (ED) crowding, but the impact of AB on consultation time has not been described. Our objectives were to determine if ED AB affects inpatient service consultation time, and operational and patient outcomes. Methods: We conducted a health records review of all ED patients referred and admitted at a university-affiliated tertiary care hospital over 60-days. A computational algorithm determined hourly ED AB at the time of consultation request, and observational cohorts were determined based on ED AB high (&gt;35% ED bed capacity occupied by admitted patients) or low (&lt;35%). The outcomes included total consultation time (TCT), ED physician initial assessment (PIA) time, ED length of stay (LOS), transfer time to inpatient bed (TTB), hospital LOS, return to ED (RTED) within 30 days, and 30-day mortality. Results: We included 2,871 patients (48% male; M = 63 years, IQR 45–78), and the low AB cohort were higher acuity (N = 1,692; 50.4% CTAS 1–2) than the high AB cohort (N = 1,179; 47.1% CTAS 1–2). Median TCT was not significantly different (low = 209min, high = 212min; p = 0.09), and there was no difference in consults completed within the 3-hour institutional time target (low = 41.1%, high = 40.9%; p = 0.89). Median ED PIA time was not significantly different (low = 66min, high = 68min; p = 0.08), however, patients seen within the funding-associated provincial ED PIA time target was significantly less during high AB (high = 82.2%, low = 89.2%; p &lt; 0.001). Median ED LOS was significantly longer during high AB (high = 12.1hr, low = 11.1hr; p = 0.009), but median hospital LOS was not different (high = 109.5hr, low = 112.4hr; p = 0.44). Median TTB was significantly longer during high AB (high = 8.0hr, low = 5.9hr; p = 0.0004). There was no difference in RTED visits (high = 12.4%, low = 10.6%; p = 0.15) or 30-day mortality (high = 8.4%, low = 9.2%; p = 0.51). Conclusion: In conclusion, consultation time is not affected by AB. However, boarding admitted patients in the ED impairs our ability to meet funding-associated performance metrics. Reducing boarding time should be an ED and hospital-wide priority, as it negatively impacts funding and delays patient care.

P108: Fast track in Calgary hospitals: measures for quality improvement

Introduction: Fast track (FT) implementation in emergency departments (ED) has shown a decrease in patient wait times, length of stay (LOS), left without being seen rates, and has increased patient satisfaction. The objective of this study was to analyze the demographics and presenting complaints of patients presenting to FT in Calgary EDs using local administrative databases to understand the current selection of FT patients, as well as to uncover potential throughput efficiencies through LOS analysis. Methods: Sunrise Clinical Manager data was pulled from the Foothills Medical Center (FMC), Peter Lougheed Center (PLC), and Rockyview General Hospital (RGH) EDs between October 2015 and September 2016. Based on consensus achieved by the Calgary FT-Minor Treatment Sub-committee, data was descriptively analyzed based on the following criteria: (1) triage profiles of the Calgary ED sites; (2) site admission rates by complaint, Canadian Triage and Acuity Scale (CTAS), vitals, and age; (3) LOS for orthopedic patients admitted from FT/Minor; and, (4) LOS in FT for non-admitted back pain patients. Results: A total of 53911 patients were triaged to FT, with 16224 patients triaged to FMC, 18299 to PLC, and 19388 to RGH. 6.9% of FT patients were admitted to hospital at FMC, 4.8% at PLC and 4.8% at RGH. 14.4% of patients at FMC, 18.3% at PLC and 17.6% at RGH were CTAS 2; 40.9% of patients at FMC, 46.2% at PLC and 37.9% at RGH were CTAS 3; 34.0% of patients at FMC, 27.8% at PLC and 33.3% at RGH were CTAS 4; 10.7% of patients at FMC, 7.7% from PLC and 11.2% for RGH were CTAS 5. For FT patients 80 years or older, 10.4% were admitted at FMC, 13.1% at PLC and 9.4% at RGH. The top FT presenting complaints at all sites were lower extremity injury, upper extremity injury, and laceration/puncture. The annual FT bed hours for patients admitted to orthopedic surgery (consultation request to time of orthopedic admission) was 802.3 hours at FMC, 441.1 PLC and 705.1 from RGH. The annual FT bed hours for patients with non-admitted back pain (FT bed to time of discharge) was 2144.3 hours from FMC, 3367.9 from PLC and 1134.9 from RGH. Conclusion: The efficiency of FT is based on streamlining low acuity patients with an expected rapid discharge from hospital. The results of this investigation will be presented to the FT-Minor Treatment Sub-committee in order to utilize current admission rates, patient profiles, and aggregate LOS to potentially improve throughput.

Assessment of consultation impact on emergency department operations through novel metrics of responsiveness and decision-making efficiency

ABSTRACT Objectives: Requests for specialty consultation are common in emergency departments (EDs) and often contribute to delays in throughput. Our objectives were to describe the contribution of the consultation process to total ED length of stay (LOS) through novel metrics and illustrate causes of delay. Methods: We conducted a prospective cross-sectional study at three Canadian tertiary care centres. Adult ED patients with requested medical/surgical consultations were enrolled. We created original metric intervals: total consultation time (TCT) defined as the interval from the initial consultation request to the disposition decision, consult response time (CRT) from the request to the consultant arrival, and decision-making interval (DMI) from arrival to the disposition decision. The consultation impact index (CII) was defined as the percentage of ED LOS consumed by the TCT. Reasons for delay were documented if time stamps exceeded preset benchmarks. Results: The median TCT for 285 patients was 138 minutes (interquartile range [IQR]: 82–239 minutes), whereas the median total ED LOS was 778 minutes (IQR 485–1,274 minutes). The median CRT was 55 minutes (IQR 21–115 minutes), and the median DMI was 58 minutes (IQR 25–126 minutes). The CII measured 26% (95% CI 23–28). Major contributors to consultation delay included urgent ward issues, simultaneous ED consultations, and the need for additional laboratory or radiographic investigations. Conclusion: The consultation process is highly variable and has an important impact on ED LOS. We describe novel measures related to consultation performance and provide an analysis of what causes delays. These results can be used to seek improvements in the consulting process.

Understanding communication between emergency and consulting physicians: a qualitative study that describes and defines the essential elements of the emergency department consultation-referral process for the junior learner

ABSTRACT Objectives: To define the important elements of an emergency department (ED) consultation request and to develop a simple model of the process. Methods: From March to September 2010, 61 physicians (21 emergency medicine [EM], 20 general surgery [GS], 20 internal medicine [IM]; 31 residents, 30 attending staff) were questioned about how junior learners should be taught about ED consultation. Two investigators independently reviewed focus group and interview transcripts using grounded theory to generate an index of themes until saturation was reached. Disagreements were resolved by consensus, yielding an inventory of themes and subthemes. All transcripts were coded using this index of themes; 30% of transcripts were coded in duplicate to determine the agreement. Results: A total of 245 themes and subthemes were identified. The agreement between reviewers was 77%. Important themes in the process were as follows: initial preparation and review of investigations by EM physician (overall endorsement 87% [range 70–100% in different groups]); identification of involved parties (patient and involved physicians) (100%); hypothesis of patient's diagnosis (75% [range 62–83%]) or question for the consulting physician (70% [range 55–95%]); urgency (100%) and stability (74% [range 62–80%]); questions from the consultant (100%); discussion/communication (98% [range 95–100%]); and feedback (98% [range 95–100%]). These components were reorganized into a simple framework (PIQUED). Each clinical specialty significantly contributed to the model (χ2 = 7.9; p value = 0.019). Each group contributed uniquely to the final list of important elements (percent contributions: EM, 57%; GS, 41%; IM, 64%). Conclusions: We define important elements of an ED consultation with input from emergency and consulting physicians. We propose a model that organizes these elements into a simple framework (PIQUED) that may be valuable for junior learners.