The interprofessional learning experience: Findings from a qualitative study based in an outpatient setting

Neurology is often perceived as a difficult discipline by medical students, yet it is an essential part of medical training. While the most common disorders of the nervous system can be observed in the outpatient setting, positive neurological signs are more likely to be found in neurology wards. We aimed to compare the impact of a neurology outpatient versus inpatient rotation setting on the grades obtained by medical students as a proxy measure of the learning outcomes. We compared the results obtained by fourth year medical students in practical (OSCE) and multiple choice question (MCQ) exams in neurology, between students whose main (total of 24h contact) teaching allocation was either the outpatient or inpatient setting, controlling for students' gender, teacher, academic year and student' previous achievement (measured by their scores on practical evaluation). A total of 1127 students were included, of whom 644 (57.14%) were allocated mainly to the neurology ward and 483 (42.86%) to the outpatient clinic. Students assigned to the ward obtained significantly higher grades in the OSCE and MCQ exams than those placed in the outpatient clinic. Teaching setting was an independent predictor of both classifications after adjustment. The teaching setting had a significant impact on the learning outcomes. This may be due to a higher likelihood of observing abnormal neurological signs or to more student-centered teaching on the ward. These results highlight the importance of a balanced distribution of students by different clinical settings.

Early pregnancy loss (EPL), or miscarriage, is the most common complication of early pregnancy, and many patients experiencing EPL present to the emergency department (ED). Little is known about how patients who present to the ED with EPL differ from those who present to outpatient clinics and how their management and outcomes differ. To compare the management and outcomes of patients with EPL who present to the ED vs outpatient clinics. This retrospective cohort study used the IBM MarketScan Research Database, a national insurance claims database. Participants were pregnant people aged 15 to 49 years in the US who presented to either an ED or outpatient clinic for initial diagnosis of EPL from October 2015 through December 2019. Data analysis was performed from May 2021 to March 2022. The primary exposure was location of service (ED vs outpatient clinic). Other exposures of interest included demographic characteristics, current pregnancy history, and comorbidities. The primary outcome was EPL management type (surgical, medication, or expectant management). Complications, including blood transfusion and hospitalization, and characteristics associated with location of service were also evaluated. Bivariable analyses and multivariable logistic regression were used for data analysis. A total of 117 749 patients with EPL diagnoses were identified, with a mean (SD) age of 31.8 (6.1) years. Of these patients, 20 826 (17.7%) initially presented to the ED, and 96 923 (82.3%) presented to outpatient clinics. Compared with the outpatient setting, patients in the ED were less likely to receive surgical (2925 patients [14.0%] vs 23 588 patients [24.3%]) or medication (1116 patients [5.4%] vs 10 878 patients [11.2%]) management. In the adjusted analysis, characteristics associated with decreased odds of active (surgical or medication) vs expectant management included ED (vs outpatient) presentation (adjusted odds ratio [aOR], 0.46; 95% CI, 0.44-0.47), urban location (aOR, 0.87; 95% CI, 0.82-0.91), and being a dependent on an insurance policy (vs primary policy holder) (aOR, 0.71; 95% CI, 0.67-0.74); whereas older age (aOR per 1-year increase 1.01; 95% CI, 1.01-1.01), established prenatal care (aOR, 2.35; 95% CI, 2.29-2.42), and medical comorbidities (aOR, 1.05; 95% CI, 1.02-1.09) were associated with increased odds of receiving active management. Patients in the ED were more likely than those in outpatient clinics to need a blood transfusion (287 patients [1.4%] vs 202 patients [0.2%]) or hospitalization (463 patients [2.2%] vs 472 patients [0.5%]), but complications were low regardless of location of service. In this cohort study of privately insured patients with EPL, differences in management between the ED vs outpatient setting may reflect barriers to accessing comprehensive EPL management options. More research is needed to understand these significant differences in management approaches by practice setting, and to what extent EPL management reflects patient preferences in both outpatient and ED settings.

Current wound management through the use of a split-thickness skin graft often requires hospital admission, a period of immobility, attentive donor site wound care and pain management. This study evaluates the feasibility of using a novel epidermal graft-harvesting device (CelluTome) that allows pain-free epidermal skin grafting in the outpatient clinic setting. A prospective series of 35 patients was performed in 2 centres, involving 10 acute and 25 chronic wounds. All patients were subjected to epidermal grafting in the outpatient specialist clinic, without the use of anaesthesia, and allowed to return home after the procedure. Completely healed wounds were noted in 22 patients (62·9%). The overall mean time for 50% and 100% reduction in wound size was 3·31 ± 2·33 and 5·91 ± 3·48 weeks, respectively. There was no significant difference in healing times between the acute and chronic wounds (50% reduction in wound size; acute 2·20 ± 0·91 weeks versus chronic 3·73 ± 2·63 weeks, P = 0·171. Hundred percent reduction in wound size; acute 4·80 ± 1·61 weeks versus chronic 6·83 ± 4·47 weeks, P = 0·183). The mean time for donor site healing was 5·49 ± 1·48 days. The mean pain score during graft harvest was 1·42 ± 0·95, and the donor site Vancouver Scar Scale was 0 for all cases at 6 weeks. This automated device offers autologous skin harvesting in the outpatient setting with minimal or no pain and a scar free donor site, equally benefiting both the acute and chronic wounds. It has the potential to save NHS resources by eliminating the need for theatre space and a hospital bed while at the same time benefiting patient care.

The necessity of treating hypertrophic burn scars has expanded significantly with increased burn survivorship. Ablative lasers, such as carbon dioxide (CO2) lasers, have been the most common nonoperative option for improving functional outcomes in severe recalcitrant hypertrophic burn scars. However, the overwhelming majority of ablative lasers used for this indication require a combination of systemic analgesia, sedation, and/or general anesthesia due to the painful nature of the procedure. More recently, the technology of ablative lasers has advanced and is more tolerable than their first-generation counterparts. Herein, we hypothesized that refractory hypertrophic burn scars can be treated by a CO2 laser in an outpatient clinic. We enrolled 17 consecutive patients with chronic hypertrophic burn scars that were treated with a CO2 laser. All patients were treated in the outpatient clinic with a combination of a topical solution (23% lidocaine and 7% tetracaine) applied to the scar 30 minutes before the procedure, Cryo 6 air chiller by Zimmer, and some patients received a mixture of N2O/O2. Laser treatments were repeated every 4 to 8 weeks until the patient's goals were met. Each patient completed a standardized questionnaire to assess tolerability and patient satisfaction of functional results. All patients tolerated the laser well in the outpatient clinic setting, with 0% indicating "not tolerable," 70.6% "tolerable," and 29.4% "very tolerable." Each patient received more than 1 laser treatment for the following complaints: decreased range of motion (n = 16, 94.1%), pain (n = 11, 64.7%), or pruritis (n = 12, 70.6%). Patients were also satisfied with the results of the laser treatments ("no improvement or worsened" = 0%, "improved" = 47.1%, and "significant improvement" = 52.9%). The age of patient, type of burn, location of burn, presence of skin graft, or age of scar did not significantly affect the tolerability of treatment or satisfaction of outcome. The treatment of chronic hypertrophic burn scars with a CO2 laser is well tolerated in an outpatient clinic setting in select patients. Patients reported a high level of satisfaction with notable improvement in functional and cosmetic outcomes.

262 Background: Patients with cancer are at particularly high risk for falls and unfortunately may suffer worse outcomes with falls. Patients with cancer are at increased risk for fractures due to bony metastases, and worse subsequent bleeding due to thrombocytopenia from disease or from prophylaxis or treatment for deep vein thromboses. In 2020, there were 10 falls among patients with cancer in NewYork Presbyterian/Weill Cornell Medicine outpatient oncology clinics, with a fall rate of 0.31 falls per 1000 patient visit. In 2019, there were 14 falls (0.39 falls per 1000 patient visits).The aim of this project is to reduce the total number of falls and overall fall rate by 50% in NewYork Presbyterian/Weill Cornell Medicine outpatient oncology clinic areas by December 30, 2021. Methods: In Plan-Do-Study-Act (PDSA) cycle in February 2021, we identified key stakeholders (nurses, medical assistants, nurse navigators, and clinic managers) in NYP/Weill Cornell oncology outpatient areas. We engaged key stakeholders in a series of interactive conferences to introduce and implement quality improvement tools (root cause analysis and process mapping) with outpatient teams to identify risk factors for patients who fell in NYP/Weill Cornell oncology outpatient areas from 01/2020-12/2021. A standardized post-fall huddle process was implemented, and prior falls were reviewed using this process. Interventions were based on these identified risk factors to prevent falls in the outpatient clinic areas. In the second PDSA cycle which began April 1, 2021, a new handoff process was initiated in the outpatient clinic setting. Prior to the end of the shift, the charge nurse cross references the “G Drive list” with patient list for the following day and identifies patients with previous falls or those identified by nurses as being high risk for falls. This list is located in a commonly used, HIPAA compliant file location, which was already part of the normal scheduling workflow. These patients are then discussed in the daily huddle to create awareness by all staff and provide “handoff” between visits which by design cannot happen nurse to nurse with each visit. The team has been reviewing the list monthly to develop a sustainability plan. Results: Since the completion of the interactive QI conferences in PDSA cycle 1, there have zero additional falls in the oncology outpatient clinic areas. Continuing on into PDSA cycle 2 with the new handoff process, there have not been any additional falls. Conclusions: This project demonstrates an effective QI intervention to reduce falls in the outpatient oncology areas and prevent injuries in this vulnerable population. This multidisciplinary approach to identifying root causes for falls and reviewing our processes for monitoring patients in our infusion areas ultimately has led to significant reduction in falls. It has also empowered key stakeholders in our oncology clinics with QI tools to address other areas for improvement.

As understanding of the impact of trauma on children has grown, there has been increasing interest in the use of screening the medical setting to identify which children at risk may be symptomatic. This study was undertaken to determine whether the use of a trauma assessment tool to screen for trauma symptoms in the setting of a foster care clinic was feasible and more sensitive than non-standardized approaches in the context of outpatient primary care. Using a chart review of trauma symptom identification before and after the implementation of the Trauma Symptom Checklist for Children (TSC-C) and the Trauma Symptom Checklist for Young Children (TSC-YC), validated trauma assessment tools, we looked at the feasibility of use of this tool and likelihood of trauma symptom identification. 73 % (n = 204) of eligible patients had a trauma screening tool in the medical record following the introduction of the use of the TSC. Detection of trauma symptoms was higher in the screening period than in the baseline period for the entire population (78 vs. 46 %, p < 0.0001), and trauma symptoms were identified with more specificity following the introduction of, and likely due to, formal trauma screening. However, there were limitations as to feasibility in the outpatient medical clinic. In conclusion, the use of the TSC-C and TSC-YC in the setting of an outpatient foster care evaluation clinic increased rates and precision of identification of trauma symptoms, but had limitations to its feasibility of use in the outpatient clinic setting.

A rising trend is being observed in enhancing Inter-Professional Education and Collaborative Practice (IPECP) in health care settings. Empirical evidence on its effects, particularly in youth settings, remains limited. This study examined the moderating role of inter-professional learning in the relation between youth work practitioners’ self-efficacy in social work and their creative self-efficacy and innovative behaviour. A total of 227 youth work practitioners from sixteen district-based youth services in Hong Kong were invited to participate in a survey. The results of regression analyses indicate a positive association between practitioners’ sense of self-efficacy in social work and their creative self-efficacy and innovative behaviour. They also show a positive association between practitioners’ inter-professional learning experience and their creative self-efficacy and innovative behaviour. However, concerning the interaction effect between self-efficacy in social work and inter-professional learning, the results indicate that the positive relationship between self-efficacy in social work and creative self-efficacy and innovative behaviour was weaker for practitioners who had a higher level of inter-professional learning. The promotion of IPECP and the preparation of social workers to be collaboration-ready were deemed essential in fostering an effective multi-agency and multi-profession partnership, especially for seasoned practitioners who were more likely to possess a silo mentality.

A review of simulation-enhanced, team-based cardiopulmonary resuscitation training for undergraduate students.

74.3 CHALLENGES IN IMPLEMENTATION OF EVIDENCE-BASED TREATMENT INTERVENTIONS FOR EATING DISORDERS IN OUTPATIENT SETTINGS

BackgroundUsing treatable traits as a management approach in bronchiectasis involves determining identifiable, clinically relevant, measurable and treatable problems to develop a management strategy in collaboration with the patient. ObjectiveTo identify new treatable traits not previously reported in the literature and treatment strategies for new and existing traits that could be implemented in an outpatient clinic or community setting by an allied health professional or nurse in adults with bronchiectasis. MethodsA scoping review was conducted with searches of MEDLINE, CINAHL, AMED, Embase, Cochrane Central Register of Controlled Trials and PsycInfo. The search yielded 9963 articles with 255 articles proceeding to full text review and 114 articles included for data extraction. ResultsSixteen new traits were identified, including fatigue (number of studies with new trait (n) = 13), physical inactivity (n = 13), reduced peripheral muscle power and/or strength (n = 12), respiratory muscle weakness (n = 9) and sedentarism (n = 6). The main treatment strategies for new and existing traits were airway clearance therapy (number of citations (n) = 86), pulmonary rehabilitation (n = 58), inspiratory muscle training (n = 20) and nebulised saline (n = 12). ConclusionThis review identifies several new traits in bronchiectasis and highlights the common treatments for new and existing traits that can be implemented in a treatable traits approach in an outpatient clinic or community setting by an allied health professional or nurse.

Background: Minimally invasive surgical therapies (MISTs) for bladder outflow obstruction are now commonplace in many urological centers, often performed as day case procedures under general anesthetic or local anesthetic (LA) with sedation. Our center has adopted an outpatient clinic LA-only setting to deliver Rezum, Urolift, and iTind using prostatic block and LA gel. We present our 1-year outcomes to determine the feasibility of delivering MIST in this setting. Methods: We retrospectively audited outcomes, collecting data on patient demographics, pre- and postoperative symptom questionnaires, flowmetry tests, and visual analogue scores (VASs) during the procedure. We compared pre- and postoperative changes using a paired t test, using a p value of <0.05 as significant. Results: There were 81 procedures performed: 38 (46.9%) Rezum, 22 (27.2%) Urolift, and 21 (25.9%) iTind. The median age was 68 (interquartile range: 63-74). Preoperatively the mean International Prostate Symptom Score (IPSS) was 20.2 (±7), quality of life (QOL) score 4.6 (±1.4), Qmax 10.7 mL/s (±5.3), prostate serum antigen 2.5 (±3.1), and prostate size 48.8 mLs (±20.9). 70.4% of patients were on an α-blocker, and 44.4% on a 5-α-reductase inhibitors (ARI). The mean VAS was 4.3 (±2.8) out of 10. The total immediate postoperative complication rate was 11.1%, all less than Clavien-Dindo III. 91.4% attended the 3-month follow-up. Postoperatively the mean IPSS was 11.3 (±7.1) (44.1% reduction, p < 0.01), the QOL score 2.4 (±1.5) (47.8% reduction, p < 0.01), and the Qmax 13.1 mL/s (±5.5) (22.4% improvement, p < 0.01). Patients on an α-blocker had reduced to 34.6%, and 5ARIs to 13.6%. Conclusion: We demonstrate the feasibility of delivering MIST under LA alone, without sedation, and report significant improvements in symptom scores and flowmetry outcomes. Patients tolerate the treatment well without sedation and have a short stay for their procedure, enabling the service to be delivered in an outpatient clinic setting, improving inpatient waiting lists and resource allocation to outpatient setting. Further research is required for long-term outcomes, but early results are promising in driving a change in the delivery of MIST.

224 Background: Cancer Treatment Centers of America (CTCA), a national network of five hospitals, implemented a new survey instrument and methodology to gather patient experience data in the outpatient setting. While borrowing many questions from its vendors’ client base, the network also added questions considered pivotal to understanding the critical dimensions of care deemed most relevant to the oncology patient. Surveying includes 100% of all patients first contacted via the U.S. mail and subsequently using e-surveys. Methods: Data is collected, with the ability to be segmented by cancer type; for medical, surgical and radiation oncologists with respect to confidence and likelihood of recommending. For each specialty, an open ended question has been added for the patient to elaborate upon his/her rating. Further, several questions have been added to reflect key dimensions of care specific to the oncology such as emotional needs, family involvement and information, sensitivity to personal difficulties associated with treatment, drawing blood and IV discomfort, and involvement in care decisions, to name a few. Results: The revised approach has resulted in greater than a 200% increase in responses, at a cost reduction, cognizant of the growing sophistication of the population served in using technology as part of the patient experience feedback process. Results at three months post-implementation have yielded the findings in the Table. Conclusions: Since implementation, not only have completed surveys increased with respect to easily accessible discrete quantitative data, qualitative information has grown exponentially. This has resulted in more meaningful and robust data around which to focus, including specialty data at the disease and provider levels. The revisions also substantially support CTCA centers’ Magnet journey, including question dimensions and unit level reporting. [Table: see text]

Background and Purpose: Transitions of care, specifically between inpatient and outpatient care settings can be a point of vulnerability in the care of stroke patients. As patients transfer from inpatient care facilities to outpatient clinics, information can become lost resulting in delays in care, a slower recovery, and patient and family frustration. The purpose of this program is to provide a link between the inpatient and outpatient care settings and improve the coordination of care along the continuum by communicating to the outpatient providers essential information about the stroke patients they will be seeing for follow up. Methods: In order to improve the transition of care between care settings, a two-part program was used. First, the Stroke Advanced Practice Nurse along with the inpatient Neurology team completes a discharge timeout to collect and verify essential information, such as the final diagnosis, suspected stroke etiology, discharge medications, follow up appointments, and transitional care issues such as pending studies. This information is then compiled into a transitional care matrix, which is shared on a weekly basis with the outpatient clinicians who will be seeing the patients that week, allowing them to anticipate and prepare for the follow ups and the patients’ needs. Since initiation in April 2018, 95 stroke patients’ plans of care have been reviewed using the above process. Results: Use of the discharge timeout and transitional care matrix has resulted in improved transitions of care. The process has resulted in more consistent and prompter scheduling of follow up appointments in the outpatient stroke clinic. Furthermore, the transitional care matrix that is shared with outpatient clinicians has helped them to be more prepared for appointments and has created an atmosphere of collaboration between different stroke providers. Conclusions: In conclusion, the discharge timeout and transitional care matrix process has shown to be a valuable tool in the transition of care for stroke patients between the inpatient and outpatient settings, resulting in fewer delays in care and improved anticipation of care needs.

Multimorbidity in adults with epilepsy attending an outpatient epilepsy clinic.

Duration of colonization and risk factors for prolonged carriage of vancomycin-resistant enterococci after discharge from the hospital