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STUDY DESIGN: Scoping Review. OBJECTIVE: To review the literature and summarize information on checklists and algorithms for responding to intraoperative neuromonitoring (IONM) alerts and management of intraoperative spinal cord injuries (ISCIs). METHODS: MEDLINE® was searched from inception through January 26, 2022 as were sources of grey literature. We attempted to obtain guidelines and/or consensus statements from the following sources: American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), American Academy of Neurology (AAN), American Clinical Neurophysiology Society, NASS (North American Spine Society), and other spine surgery organizations. RESULTS: Of 16 studies reporting on management strategies for ISCIs, two were publications of consensus meetings which were conducted according to the Delphi method and eight were retrospective cohort studies. The remaining six studies were narrative reviews that proposed intraoperative checklists and management strategies for IONM alerts. Of note, 56% of included studies focused only on patients undergoing spinal deformity surgery. Intraoperative considerations and measures taken in the event of an ISCI are divided and reported in three categories of i) Anesthesiologic, ii) Neurophysiological/Technical, and iii) Surgical management strategies. CONCLUSION: There is a paucity of literature on comparative effectiveness and harms of management strategies in response to an IONM alert and possible ISCI. There is a pressing need to develop a standardized checklist and care pathway to avoid and minimize the risk of postoperative neurologic sequelae.

The article discusses the implementation of national quality improvement programs for emergency surgery patients in the UK, focusing on hip fracture and emergency laparotomy cases. These programs, such as the UK National Hip Fracture Database (NHFD) and the UK National Emergency Laparotomy Audit (NELA), have led to improved outcomes and reduced mortality rates for patients. However, there are concerns about unintended consequences, resource allocation, and potential impacts on other patient groups. The need for a nuanced systems understanding of the effects of standardized care pathways is emphasized, highlighting the importance of balancing quality improvement efforts with broader healthcare considerations. [Extracted from the article]

Background: Older adults often experience adverse health outcomes including malnutrition following discharge from emergency departments (ED). Discharge to community care is a transitionary time where nutritional vulnerability could be mitigated with the instigation of targeted nutrition care pathways in ED settings. Aims and objectives: This scoping review aimed to establish and describe the level of nutrition care provided to older adults admitted and subsequently discharged from EDs. Research design: Systematic searches of nine academic and grey literature databases (Medline (Ovid), Pubmed, CINAHL Complete (EBSCOhost), EMBASE, Cochrane Library and Scopus), grey literature sources (DART-Europe E-theses portal, Open Grey, and Trip Medical database) and four websites (Google, Google Scholar, NICE and LENUS) for relevant professional and organisational publications of research, policy, practice, and guidelines between January 2011 to 2023 were completed. Eligible studies included a population of older adults (≥ 65 years) with an ED attendance and subsequent community discharge, and where nutrition screening had identified malnutrition. Data were extracted on the level of nutrition and dietetic care initiated for older adults in the ED according to the Nutrition Care Process Model and summarised descriptively. Results: Overall, 22 studies were included in the review. Nutrition status was screened on admission to the ED using validated tools: Mini Nutritional Assessment-Short Form (n = 13), Malnutrition Universal Screening Tool (n = 2), Short Nutritional Assessment Questionnaire (n = 2), NRS-2002 (n = 1) and the Mini Nutritional Assessment – Full Form (n = 1). A full nutrition assessment was reported by 5 studies. Only one study referred to documentation of malnutrition in healthcare records. Subsequent nutrition intervention after discharge from the ED for older adults was not described in any study. Conclusion: While there is evidence to support malnutrition screening is taking place in EDs, there is a lack of information about subsequent nutrition care including assessment and therapy interventions. This points to the need for comprehensive exploration of nutrition care pathways, practice, policy, and research to inform models of integrated care for older persons. [ABSTRACT FROM AUTHOR]

Introduction: Supported accommodations (SAs) are key components of community mental health care, but little is known about residents' care pathways. This study analysed the care pathways of residents of SAs, and factors associated with their age of entry and length of stay. Methods: A random sample of SAs' residents in Portugal was interviewed and a questionnaire was specifically developed to assess their care pathways. Associations between sociodemographic and clinical characteristics, age of entry and length of stay, were analysed using hierarchical regression. Results: Overall, 213 residents of 43 different SAs participated. Their mean age was 55 years. Most were male, single, pensioners and had early-onset psychotic disorders. On average, they integrated the current SA at around 50 years old and had a 4.5 year length of stay. Most participants had been in another SA before (35.0% in more supported, 33.8% in less supported and 6.3% in similarly supported SAs). Conclusions: Findings suggest that residents spend several years in the residential pathway, with a significant proportion moving to more supported SAs. This calls for increasing the number of SAs with different typologies and developing coordinated community supports. [ABSTRACT FROM AUTHOR]

Introduction: The global population is ageing, and healthcare systems continue to adopt outdated social models of ageing that do not respond to older people's needs. The aim of this study was to explore the experiences of participants in the implementation of the Transcultural social‐ethical‐care (TEC‐MED) model for integrated community care. Methods: A qualitative descriptive research study was conducted. Qualitative data were collected through individual interviews and focus groups with purposive sampling. Results: We gathered experiences from five older people, five informal caregivers, two training agents (nurses), six healthcare professionals and eight stakeholders (senior management of businesses, public administrators, researchers and educators). Four themes were extracted: TEC‐MED as a new model of home care, TEC‐MED model outcome, key role of training agent and platform and resources. Overall, all the participants were satisfied with the model and various positive outcomes were found. The TEC‐MED model of care was inclusive and personalised and bridged the communication and integration gaps between different services for the care of dependent older people and their caregivers in the community. Recommendations were made for improvements to the model. Conclusion: New models of care that are inclusive, personalised and integrated are necessary to respond to the multiple needs of the older people. A model that integrates the multiple skills of healthcare professionals is an optimum solution in the care of the older people and their caregivers in Mediterranean countries. Similar research is imperative for other healthcare systems to help them prepare adequately to respond effectively to the needs of present and new generations of older people. Implications for Practice: The TEC‐MED model presents a promising approach to addressing the complex care needs of older people and their caregivers by fostering inclusivity, personalisation and integration across services. For nursing practice, this model emphasizes the importance of multidisciplinary collaboration and the role of nurses in facilitating the adoption of new care strategies. Implementing such models in everyday practice could improve the quality of care provided to older adults, enhancing communication between healthcare providers and ensuring that care is more aligned with the individual needs of patients. Furthermore, integrating digital platforms and targeted resources, as highlighted in the TEC‐MED model, can aid in overcoming existing barriers in healthcare systems, improving the coordination of care at the community level. [ABSTRACT FROM AUTHOR]

Background: Time-driven activity-based costing (TDABC) and activity-based costing (ABC) are methods used in the healthcare sector to assess the costs of patient care pathways. These methods help identify opportunities for optimizing and reducing activity times without compromising the quality of care. TDABC is recommended in the Value-Based Healthcare (VBHC) model to assess the outcomes of care pathways in relation to their associated costs. By focusing on the creation of value for patients, TDABC helps identify the interventions and processes that provide the most value in terms of clinical outcomes and patient satisfaction. This enables healthcare organizations to make informed decisions on improvements that will maximize value for patients. The aim of the study is to evaluate the cost of the oncology thoracic surgery care pathway prior to and following the implementation of digital health solution. Methods: We have chosen to use the TDABC and ABC methods to calculate the costs of care pathway for oncology patients undergoing thoracic surgery in two healthcare establishments prior to and following the implementation of a digital health solution. By using these methods, we were able to calculate the costs associated with each stage of the patients' care pathway. This has given us a clearer picture of the costs associated with each activity and a better understanding of the sources of expenditure. Results: The results show that implementing the digital health solution and applying the principles of the VBHC model have provided tangible benefits in terms of reviewing processes and the roles of the various players involved, eliminating unnecessary or non-value-added activities, automating administrative or repetitive tasks, and improving coordination between the two healthcare establishments and between healthcare professionals. These improvements have contributed to better patient care. Conclusions: Given the success observed in this pilot project, decision-makers chose to persistently implement this digital health solution for specific care pathways over the long term. Additionally, there is a commitment to further enhance the platform to align closely with the needs and the expectations of healthcare professionals. This proactive approach aims to ensure optimal utilization of resources, ultimately providing the best care to patients. [ABSTRACT FROM AUTHOR]

ABSTRACT Aim(s) Design Methods Results Conclusion Impact Patient and Public Contribution This study reports on the implementation of a registered advanced nurse practitioner intervention. Aims include improving access, service user outcomes and integration between primary and secondary care.This paper reports the quantitative results of a mixed methods implementation study. Qualitative data are reported separately. The PARiHS framework informs the implementation process itself, with considerations for nurses and other healthcare professionals explored.The CORE‐OM 34 item rating scale was administered both pre‐ and post‐intervention. Service user attendances in secondary care was monitored.Findings suggest that the intervention was associated with clinically significant improvements in global or generic distress, reported by service users, as evidenced by changes in the CORE‐OM scores. Access to care was recorded at an average of 3.6 days. Implementation science supported effective and safe implementation with clear governance structures.Registered advanced nurse practice in mental health clinics which provide full episodes of care results in improved integration and may be associated with positive patient outcomes. Implementation science is taught on Irish nursing programmes and this is important if innovative services are to be embedded in the healthcare system.The development of a model of care for mental health Registered Advanced Nurse Practitioners at the interface of primary and secondary care settings may be merited. Positive Advanced Recovery Connections may be associated with improving mental health outcomes and bolstering integration of primary and secondary care services. The utilisation of implementation science highlights the need for collaboration with all stakeholders to overcome barriers and recognise facilitators to attain the necessary model of integrated care.Peer recovery input was provided by members of the service Recovery College, with participation evident in all stages of the project. The psychosocial assessment template was also co‐designed. [ABSTRACT FROM AUTHOR]

Aims: A set of indicators to assess the quality of care for patients hospitalized for heart failure was developed by an expert working group of the Italian Health Ministry. Because a better performance profile measured using these indicators does not necessarily translate to better outcomes, a study to validate these indicators through their relationship with measurable clinical outcomes and healthcare costs supported by the Italian National Health System was carried out. Methods and results: Residents of four Italian regions (Lombardy, Marche, Lazio, and Sicily) who were newly hospitalized for heart failure (irrespective of stage and New York Heart Association class) during 2014–2015 entered in the cohort and followed up until 2019. Adherence to evidence‐based recommendations [i.e. renin–angiotensin–aldosterone system (RAS) inhibitors, beta‐blockers, mineralocorticoid receptor antagonists (MRAs), and echocardiograms (ECCs)] experienced during the first year after index discharge was assessed. Composite clinical outcomes (cardiovascular hospital admissions and all‐cause mortality) and healthcare costs (hospitalizations, drugs, and outpatient services) were assessed during the follow‐up. The restricted mean survival time at 5 years (denoted as the number of months free from clinical outcomes), the hazard of clinical outcomes (according to the Cox model), and average annual healthcare cost (expressed in euros per person‐year) were compared between adherent and non‐adherent patients. A non‐parametric bootstrap method based on 1000 resamples was used to account for uncertainty in cost‐effectiveness estimates. A total of 41 406 patients were included in this study (46.3% males, mean age 76.9 ± 9.4 years). Adherence to RAS inhibitors, beta‐blockers, MRAs, and ECCs were 64%, 57%, 62%, and 20% among the cohort members, respectively. Compared with non‐adherent patients, those who adhered to ECCs, RAS inhibitors, beta‐blockers, and MRAs experienced (i) a delay in the composite outcome of 1.6, 1.9, 1.6, and 0.6 months and reduced risks of 9% (95% confidence interval, 2–14%), 11% (7–14%), 8% (5–11%), and 4% (−1–8%), respectively; and (ii) lower (€262, €92, and €571 per year for RAS inhibitors, beta‐blockers, and MRAs, respectively) and higher costs (€511 per year for ECC). Adherence to RAS inhibitors, beta‐blockers, and MRAs showed a delay in the composite outcome and a saving of costs in 98%, 84%, and 93% of the 1000 bootstrap replications, respectively. Conclusions: Strict monitoring of patients with heart failure through regular clinical examinations and drug therapies should be considered the cornerstone of national guidelines and audits. [ABSTRACT FROM AUTHOR]

Abstract Background Older adults often experience adverse health outcomes including malnutrition following discharge from emergency departments (ED). Discharge to community care is a transitionary time where nutritional vulnerability could be mitigated with the instigation of targeted nutrition care pathways in ED settings. Aims and objectives This scoping review aimed to establish and describe the level of nutrition care provided to older adults admitted and subsequently discharged from EDs. Research design Systematic searches of nine academic and grey literature databases (Medline (Ovid), Pubmed, CINAHL Complete (EBSCOhost), EMBASE, Cochrane Library and Scopus), grey literature sources (DART-Europe E-theses portal, Open Grey, and Trip Medical database) and four websites (Google, Google Scholar, NICE and LENUS) for relevant professional and organisational publications of research, policy, practice, and guidelines between January 2011 to 2023 were completed. Eligible studies included a population of older adults (≥ 65 years) with an ED attendance and subsequent community discharge, and where nutrition screening had identified malnutrition. Data were extracted on the level of nutrition and dietetic care initiated for older adults in the ED according to the Nutrition Care Process Model and summarised descriptively. Results Overall, 22 studies were included in the review. Nutrition status was screened on admission to the ED using validated tools: Mini Nutritional Assessment-Short Form (n = 13), Malnutrition Universal Screening Tool (n = 2), Short Nutritional Assessment Questionnaire (n = 2), NRS-2002 (n = 1) and the Mini Nutritional Assessment – Full Form (n = 1). A full nutrition assessment was reported by 5 studies. Only one study referred to documentation of malnutrition in healthcare records. Subsequent nutrition intervention after discharge from the ED for older adults was not described in any study. Conclusion While there is evidence to support malnutrition screening is taking place in EDs, there is a lack of information about subsequent nutrition care including assessment and therapy interventions. This points to the need for comprehensive exploration of nutrition care pathways, practice, policy, and research to inform models of integrated care for older persons.

Abstract Background Time-driven activity-based costing (TDABC) and activity-based costing (ABC) are methods used in the healthcare sector to assess the costs of patient care pathways. These methods help identify opportunities for optimizing and reducing activity times without compromising the quality of care. TDABC is recommended in the Value-Based Healthcare (VBHC) model to assess the outcomes of care pathways in relation to their associated costs. By focusing on the creation of value for patients, TDABC helps identify the interventions and processes that provide the most value in terms of clinical outcomes and patient satisfaction. This enables healthcare organizations to make informed decisions on improvements that will maximize value for patients. The aim of the study is to evaluate the cost of the oncology thoracic surgery care pathway prior to and following the implementation of digital health solution. Methods We have chosen to use the TDABC and ABC methods to calculate the costs of care pathway for oncology patients undergoing thoracic surgery in two healthcare establishments prior to and following the implementation of a digital health solution. By using these methods, we were able to calculate the costs associated with each stage of the patients’ care pathway. This has given us a clearer picture of the costs associated with each activity and a better understanding of the sources of expenditure. Results The results show that implementing the digital health solution and applying the principles of the VBHC model have provided tangible benefits in terms of reviewing processes and the roles of the various players involved, eliminating unnecessary or non-value-added activities, automating administrative or repetitive tasks, and improving coordination between the two healthcare establishments and between healthcare professionals. These improvements have contributed to better patient care. Conclusions Given the success observed in this pilot project, decision-makers chose to persistently implement this digital health solution for specific care pathways over the long term. Additionally, there is a commitment to further enhance the platform to align closely with the needs and the expectations of healthcare professionals. This proactive approach aims to ensure optimal utilization of resources, ultimately providing the best care to patients.

Abstract Aims A set of indicators to assess the quality of care for patients hospitalized for heart failure was developed by an expert working group of the Italian Health Ministry. Because a better performance profile measured using these indicators does not necessarily translate to better outcomes, a study to validate these indicators through their relationship with measurable clinical outcomes and healthcare costs supported by the Italian National Health System was carried out. Methods and results Residents of four Italian regions (Lombardy, Marche, Lazio, and Sicily) who were newly hospitalized for heart failure (irrespective of stage and New York Heart Association class) during 2014–2015 entered in the cohort and followed up until 2019. Adherence to evidence‐based recommendations [i.e. renin–angiotensin–aldosterone system (RAS) inhibitors, beta‐blockers, mineralocorticoid receptor antagonists (MRAs), and echocardiograms (ECCs)] experienced during the first year after index discharge was assessed. Composite clinical outcomes (cardiovascular hospital admissions and all‐cause mortality) and healthcare costs (hospitalizations, drugs, and outpatient services) were assessed during the follow‐up. The restricted mean survival time at 5 years (denoted as the number of months free from clinical outcomes), the hazard of clinical outcomes (according to the Cox model), and average annual healthcare cost (expressed in euros per person‐year) were compared between adherent and non‐adherent patients. A non‐parametric bootstrap method based on 1000 resamples was used to account for uncertainty in cost‐effectiveness estimates. A total of 41 406 patients were included in this study (46.3% males, mean age 76.9 ± 9.4 years). Adherence to RAS inhibitors, beta‐blockers, MRAs, and ECCs were 64%, 57%, 62%, and 20% among the cohort members, respectively. Compared with non‐adherent patients, those who adhered to ECCs, RAS inhibitors, beta‐blockers, and MRAs experienced (i) a delay in the composite outcome of 1.6, 1.9, 1.6, and 0.6 months and reduced risks of 9% (95% confidence interval, 2–14%), 11% (7–14%), 8% (5–11%), and 4% (−1–8%), respectively; and (ii) lower (€262, €92, and €571 per year for RAS inhibitors, beta‐blockers, and MRAs, respectively) and higher costs (€511 per year for ECC). Adherence to RAS inhibitors, beta‐blockers, and MRAs showed a delay in the composite outcome and a saving of costs in 98%, 84%, and 93% of the 1000 bootstrap replications, respectively. Conclusions Strict monitoring of patients with heart failure through regular clinical examinations and drug therapies should be considered the cornerstone of national guidelines and audits.

Abstract Background Malaria is a major public health issue in Guinea and care-seeking behaviour is dominated by self-medication and delayed access to appropriate care. However early and appropriate care-seeking are essential to control and reduce complicate forms and mortality, particularly for the most vulnerable. This study was conducted to analyse the diagnostic pathway, and the factors associated with early and appropriate care-seeking for malaria patients in the Republic of Guinea. Methods A cross-sectional study was carried out between December 2022 to March 2023 in nine health districts within health facilities and at community level. The study population was confirmed malaria patients with RDT or microscopy. Kroeger’s conceptual framework was used to design the questionnaire. Conventional recourse was defined as using a healthcare facility or community services, early and appropriate care-seeking was defined as within 24 h of symptom onset in a conventional recourse, and care pathway as the sequence of recourses followed by each patient. Sankey alluvial plots were used to represent patients' diagnostic pathways, and logistic regression to identify factors associated with early and appropriate care-seeking. Results A total of 3300 malaria patients were studied, of which 1632 (49.45%) were female and 1132 (34.30%) were under 5 years of age, with a median age of 23 months. At the time of the survey, 1337 (40.52%), 1423 (43.12%), and 437 (13.85%) of patients were respectively in their first, second and third recourse. A total of 2002 (60.67%) patients had sought care from a conventional recourse as a first line. Of all patients, 1757 (53.25%) had sought care within 24 h, while 28.55% had sought early and appropriate care. In the initial stages of treatment, self-medication was the most common approach, used by 1214 (37.30%). Patients from the health districts of Boffa (Lower Guinea, coastal region) OR = 0.48 95% CI 0.33–0.70, Dabola (Upper Guinea, savanna region) OR = 0.43 95% CI 0.30–0.63 and Labe (Middle Guinea, mountain region) OR = 0.63 CI 95% 0.43–0.91 (p

Abstract Background General mental health inpatient units hold a valuable place in the stepped system of care, and for identification and treatment of people with eating disorders (EDs) or disordered eating behaviours (DEBs). This study aimed to pragmatically evaluate an evidence-informed screening and care pathway, alongside a staff education program, implemented to improve identification and treatment access for consumers with EDs and DEBs, with co-occurring psychiatric conditions, on a general mental health ward. Methods A mixed methodology design was mapped to the RE-AIM implementation framework. It encompassed medical record audits across two 3-month time points pre and post implementation of the pathway, and key informant consumer and health professional interviews. Results Process and implementation data were compared for three-month periods pre (2019, n = 348) and post-implementation (2021, n = 284). Post-implementation, intake SCOFF screening occurred in 94.7% of admissions. People with ED/DEBs diagnoses were 35 times more likely to have a SCOFF score ≥ 2 (OR = 35.2, p

Background: Malaria is a major public health issue in Guinea and care-seeking behaviour is dominated by self-medication and delayed access to appropriate care. However early and appropriate care-seeking are essential to control and reduce complicate forms and mortality, particularly for the most vulnerable. This study was conducted to analyse the diagnostic pathway, and the factors associated with early and appropriate care-seeking for malaria patients in the Republic of Guinea. Methods: A cross-sectional study was carried out between December 2022 to March 2023 in nine health districts within health facilities and at community level. The study population was confirmed malaria patients with RDT or microscopy. Kroeger's conceptual framework was used to design the questionnaire. Conventional recourse was defined as using a healthcare facility or community services, early and appropriate care-seeking was defined as within 24 h of symptom onset in a conventional recourse, and care pathway as the sequence of recourses followed by each patient. Sankey alluvial plots were used to represent patients' diagnostic pathways, and logistic regression to identify factors associated with early and appropriate care-seeking. Results: A total of 3300 malaria patients were studied, of which 1632 (49.45%) were female and 1132 (34.30%) were under 5 years of age, with a median age of 23 months. At the time of the survey, 1337 (40.52%), 1423 (43.12%), and 437 (13.85%) of patients were respectively in their first, second and third recourse. A total of 2002 (60.67%) patients had sought care from a conventional recourse as a first line. Of all patients, 1757 (53.25%) had sought care within 24 h, while 28.55% had sought early and appropriate care. In the initial stages of treatment, self-medication was the most common approach, used by 1214 (37.30%). Patients from the health districts of Boffa (Lower Guinea, coastal region) OR = 0.48 95% CI 0.33–0.70, Dabola (Upper Guinea, savanna region) OR = 0.43 95% CI 0.30–0.63 and Labe (Middle Guinea, mountain region) OR = 0.63 CI 95% 0.43–0.91 (p < 0.05) were more likely to delay appropriate care-seeking, when compared to those in Dixinn, (Conakry). However, the under 5-year-old group OR = 1.55 95% CI 1.30–1.85 (p < 0.001) and the availability of a stable monthly household income OR = 4.98 95% CI 3.03, 8.27 (p < 0.001) were positively associated with early and appropriate care seeking. Conclusion: A low rate of early and appropriate care-seeking was observed. Patients sought care through multiple means, often resulting in a delay in adequate management. The results show the need to deploy strategies adapted to the needs of communities. [ABSTRACT FROM AUTHOR]

The article offers a perspective on principles and care pathways for caries management in children. Topics discussed include advances in the science of cariology, evidence-based care pathway for caries management, prevention and restorative strategies, caries risk/susceptibility assessment, shared decision-making in oral healthcare, and active surveillance as part of restorative dental care, advances in clinical caries management for children, improvements for oral health systems.

Background: General mental health inpatient units hold a valuable place in the stepped system of care, and for identification and treatment of people with eating disorders (EDs) or disordered eating behaviours (DEBs). This study aimed to pragmatically evaluate an evidence-informed screening and care pathway, alongside a staff education program, implemented to improve identification and treatment access for consumers with EDs and DEBs, with co-occurring psychiatric conditions, on a general mental health ward. Methods: A mixed methodology design was mapped to the RE-AIM implementation framework. It encompassed medical record audits across two 3-month time points pre and post implementation of the pathway, and key informant consumer and health professional interviews. Results: Process and implementation data were compared for three-month periods pre (2019, n = 348) and post-implementation (2021, n = 284). Post-implementation, intake SCOFF screening occurred in 94.7% of admissions. People with ED/DEBs diagnoses were 35 times more likely to have a SCOFF score ≥ 2 (OR = 35.2, p <.001) with the odds of identifying previously undiagnosed DEBs 3.3 times greater (p =.002). Post-implementation, for those with an ED/DEB, dietitian referrals (p <.001) and micronutrient supplementation (p =.013) were more likely. For those with weight and height data, both absolute (-1.1 kg ± 2.2 vs. 1.3 kg ± 2.3; p <.001) and percentage weight change were significantly higher post-implementation with similarities across BMI categories. Universally, consumers and health professionals expressed that the service had "changed care for the better" encouraging therapeutic relationships, mediated by trust, that resulted in better consumer outcomes. 50 health professionals undertook tailored ED and meal support therapy education. They noted that their knowledge and confidence improved allowing value to be seen in understanding EDs and the role for care within general mental health. Conclusions: This study demonstrated that an articulated screening and care pathway could be feasibly implemented in general mental health. The evaluation demonstrated advances in ED detection and management with noted improvements in management access, care planning, physical monitoring and weight gain outcomes. Understanding stakeholders' experiences of new care practices enabled the identification of enablers and barriers for implementation, and avenues to optimise care for consumers with EDs in the general mental health setting. Plain English summary: This study looked at how to improve the identification and treatment of people with eating disorders or disordered eating behaviours in general mental health inpatient units. We wanted to see if a new screening and care pathway, along with educating staff, could make a positive difference. We checked medical records and interviewed consumers and health professionals before and after implementing these changes. After the changes, nearly all admissions were screened for eating disorders, and high scores were linked to actual eating disorders. The chances of finding disordered eating behaviours were also higher. People with eating disorders were more likely to be referred to a dietitian and have micronutrient supplements after the changes. There were also positive changes in weight for those with available data. Both consumers and health professionals said the service had improved care, building better relationships and trust. Examining and understanding people's experiences helped identify how to make care even better for those with eating disorders in general mental health settings. [ABSTRACT FROM AUTHOR]

Aims Design Methods Results Conclusion Implication The longitudinal programme of research described in this paper seeks to generate knowledge about factors influencing the implementation of a system‐level intervention, the clinical nurse leader care model, involving nurses as leaders at the frontlines of care and the outcomes achievable with successful implementation. The research programme has the following aims, (a) to clarify clinical nurse leader practice, (b) develop and empirically validate a translational model of frontline care delivery that includes clinical nurse leader practice and (c) delineate the patterns of and critical outcomes of successful implementation of the clinical nurse leader care model.This programme of research follows a knowledge‐building trajectory involving multiple study designs in both qualitative (grounded theory, case study) and quantitative (descriptive, correlational and quasi‐experimental) traditions.Multiple mixed methods within a system‐based participatory framework were used to conduct this programme of implementation–effectiveness research.Findings are demonstrating how the clinical nurse leader care model, as a complex system‐level intervention, can be implemented in diverse healthcare contexts to make a difference to patient care quality and safety. Findings also contribute to implementation science, helping to better understand the dynamic interdependencies between implementation, the interventions implemented and the contexts in which they are implemented.Findings translate into sets of evidence‐informed implementation ‘recipes’ that health systems can match to their specific contexts and needs. This allows health systems to take on strategies that both maximize resource impact within their existing structures and support achieving intended outcomes.This programme of research is producing actionable implementation and outcome evidence about ways to organize nursing knowledge and practice into care models that can be successfully adopted within real‐world healthcare settings to achieve safer and higher quality patient care. [ABSTRACT FROM AUTHOR]

The Getting It Right First Time (GIRFT) programme is a quality improvement initiative covering the National Health Service in England. The programme aims to standardise clinical practices and improve patient and system level outcomes by utilising data‐driven insights and clinically‐led recommendations. There are GIRFT workstreams for every medical and surgical specialty, including urology. Defining features of the GIRFT methodology are that it is clinically led by experienced clinicians, data‐driven, and specialty specific. Each specialty workstream conducts deep‐dive visits to every hospital, analysing performance data and engaging with clinicians and management to identify and share improvement priorities. For urology, GIRFT has completed deep‐dive visits and published reports outlining priority areas for development. Reports include recommendations pertaining to streamlining care pathways, reducing the acuity of care environments, enhancing emergency services, optimising utilisation of outpatient services, and workforce training and utilisation. The GIRFT academy provides guides for implementing best practices specific to priority areas of care. These include important disease pathways, and GIRFT‐advocated innovations such as urology investigation units and urology area networks. GIRFT offers clinical transformation, cost reduction, equity in access to care, and leaner models of care that are often more environmentally sustainable. Evaluation efforts of the programme have focussed on assessing the adoption of GIRFT recommendations, understanding barriers to change, and modelling the climate impact of advocated practices. [ABSTRACT FROM AUTHOR]

Functional Neurological Disorders (FNDs) are characterized by the symptoms experienced by the individuals but also by how they express personal experiences and concerns related to the clinical condition. Access to care programs for functional neurological symptoms appears challenging and may entail circular, self-perpetuating healthcare pathways. Given the challenging and misleading interpretations around FND, in advocating for care pathways beyond medical therapies, we designed a scoping review to map recently suggested practices and interventions. We identified 31 relevant papers published between January 2018 and December 2022. Most of the literature was gathered from the US and UK healthcare experiences, with documented interventions provided by multi-professional teams or stand-alone psychotherapists. We found different care pathways addressing either motor or non-motor manifestations. Persons with Functional Motor Disorder are more likely to be referred to physical therapy first, while Persons suffering from Non-Epileptic Seizures are to mental health services. A narrow focus was given to minor components of multimodal approaches (e.g. social workers, and occupational therapists). High heterogeneity was found between assessment instruments as well, reflecting different perspectives in selecting treatment outcomes (e.g., reduction of non-epileptic events, psychological functioning, motor symptoms). Among healthcare professionals, neurologists and (neuro)psychiatrists are typically engaged in formulating and delivering diagnoses, while treatment is often administered by physiotherapists and/or psychologists. In the context of FNDs, the complex etiopathological nature of the condition, including comorbidities, suggests the recommendation of multidisciplinary treatments adopting a stepped care model progressing from standard to higher level individualized modules may better suit individual complexities. [ABSTRACT FROM AUTHOR]

Purpose: The Pediatric Oncology Group of Ontario (POGO) supported an effort to implement infection management care pathways based on clinical practice guidelines, to improve the consistency of infection management in pediatric cancer patients. The objective of this qualitative study was to describe the perspective of healthcare professionals (HCPs) following implementation. Methods: Four tertiary pediatric oncology centers in Ontario, Canada, implemented the pathways. We randomly identified three HCPs per group (clinical pharmacists; nurse case managers, educators or practitioners and physician assistants; pediatric oncology fellows; or pediatric oncology staff physicians) per site and invited them to participate in a qualitative interview. One-on-one interviews were conducted remotely, followed by thematic analysis of interview transcripts. Results: A total of 66 invitations were extended and 42 HCPs participated. Identified themes were: (1) implementation approach, (2) access and navigation, (3) engagement, (4) concerns, (5) workplace benefits, (6) reception, and (7) provincial harmonization. HCPs preferred in-person implementation strategies over e-mail communication. They identified teaching/educational utility and benefits to non-oncology departments and non-tertiary centers participating in shared care of patients. Other positive aspects related to evidence-based practice, safety, supporting oncology HCPs, and benefits to patients and families. Concerns included need to ensure users applied clinical judgement and loss of autonomy. Provincial harmonization of practice was viewed positively, although potential logistical and institutional cultural barriers were raised. Conclusions: Following infection management care pathway implementation, HCPs described educational utility and benefits to non-oncology departments, oncology HCPs, patients, and families. Our findings may facilitate future infection management care pathway provincial harmonization. [ABSTRACT FROM AUTHOR]

Background Health policymakers have tried to improve the care pathway for cancer patients by improving collaboration between participating healthcare professionals by involving the general practitioner (GP).Objective(s) To explore how patients, GPs, oncologists and nurses interacted and how they perceived, in their practice, professional roles, collaboration, and cancer care pathways.Methods Between January 2018 and December 2021, we conducted a qualitative study that combined phenomenology and a general inductive analysis, based on semi-structured interviews with cancer patients and their GPs, oncologists, and nurses in France.Results Our analysis of 59 interviews showed that the stakeholders had different perceptions of the cancer care pathway. Task division was implicit and depended on what each health professional thought he/she should be doing; this led to the blurring of certain tasks (announcement of the diagnosis, coordination, and follow-up). The healthcare professionals were stuck in frameworks centred on their own needs and expectations and were unaware of the other health professionals’ needs and expectations. Outside the hospital, GPs and nurses worked in isolation; they were not aware of the other stakeholders and did not communicate with them. GPs and nurses justified this attitude by the lack of a perceived need. Interprofessional communication varied as a function of the needs, involvement and knowledge of the other health professionals and was often mediated by the patient.Conclusion In the cancer management in France, to improve cancer care pathway, there is a need to train healthcare professionals in interprofessional collaboration delivering care tailored to patient needs and preferences.

Background During pregnancy and the postpartum period, women’s mental health can deteriorate quickly. Timely and easy access to services is critically important; however, little is known about the pathways women take to access services. Previous research has shown that women from ethnic minority groups in the United Kingdom experience more access issues compared to the White British women. Aim To describe pathways taken to specialist community perinatal mental health services and explore how they vary across services and ethnic groups. Methods This is a two-site, longitudinal retrospective service evaluation conducted in Birmingham and London during 6 months (1 July–31 December 2019). Electronic records of 228 women were accessed and data were extracted on help-seeking behaviour, referral process and the type of pathway (i.e. simple or complex). Data were collected using the adapted World Health Organization encounter form and analysed using uni- and multivariable analyses. Results The median time from the start of perinatal mental illness to contact with perinatal mental health services was 20 weeks. The majority of patients accessed perinatal mental health services through primary care (69%) and their pathway was simple, that is they saw one service before perinatal mental health services (63%). The simple pathway was used as a proxy for accessible services. In Birmingham, compared to London, more referrals came from secondary care, more women were experiencing current deterioration in mental health, and more women followed a complex pathway. Despite differences between ethnic groups regarding type of pathway and duration of patient journey, there was no evidence of difference when models controlled for confounders such as clinical presentation, general characteristics and location. The service’s location was the strongest predictor of the type of pathway and duration of patient journey. Limitations The heterogeneity among categorised ethnic groups; data extracted from available electronic records and not validated with patient’s own accounts of their pathways to care; unanalysed declined referrals; the study was conducted before the COVID-19 pandemic and pathways may be different in the post-COVID-19 period. Conclusion The study provides important insights into how patients find their way to community perinatal mental health services. It shows that there is a great degree of variability in the time taken to get into these services, and the pathway taken. This variation does not come from different needs of patients or different clinical presentations but rather from service-level factors. Future work The studied community perinatal mental health services in the United Kingdom operate with a significant degree of variability in the types and characteristics of patient pathways. Future research should explore these issues on the national and international levels. Additionally, future research should explore the reasons for the different pathways taken and the outcomes and risks associated with them. Funding This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number 17/105/14. Plain language summary When women are pregnant or have just had a baby, their mental health can get worse quickly. It is very important for them to get help quickly and easily, but we do not know much about how women find and use perinatal mental health services during this time. Women from ethnic minority backgrounds in the United Kingdom often have more trouble accessing these services than White British women. In this study, we wanted to find out how women from different ethnic groups get to mental health services when they are pregnant or after having a baby. We looked at information from Birmingham and London, collected over 6 months in 2019. We studied the records of 228 women. Here is what we found: The middle time from when perinatal mental illness began until contact with perinatal mental health services was 20 weeks. Most women accessed services through primary care and their journey was straightforward. For example, after contacting their family doctor, they were next seen by the perinatal mental health service. When we looked at things like how unwell someone was, where they lived, and their background, we did not find any big differences between different ethnic groups in how they got to perinatal services. The place where the service was located was the most important factor in deciding how patients got there. Limitations First, we put together individuals from different ethnic groups to study them, but this might hide the differences between each group. Second, we only used information from patients’ records, and we did not check with the patients themselves to make sure everything was right. Lastly, we did this study before the COVID-19 pandemic, so the way people get health care might have changed since then. Conclusion This study is the first to look at how women get to community mental health services for mothers. We found that it takes different amounts of time for women to reach these services, and they follow different paths. This difference does not seem to be because of what the patients need or how unwell they are, but because of how the services work. In the future, we should study what happens and what problems might come from these different ways of getting help.

With the worldwide increase in life span, surgical patients are becoming older and have a greater propensity for postoperative cognitive impairment, either new onset or through deterioration of an existing condition; in both conditions, knowledge of the patient's preoperative cognitive function and postoperative cognitive trajectory is imperative. We describe the clinical utility of a tablet-based technique for rapid assessment of the memory and attentiveness domains required for executive function. The pathogenic mechanisms for perioperative neurocognitive disorders have been investigated in animal models in which excessive and/or prolonged postoperative neuroinflammation has emerged as a likely contender. The cellular and molecular species involved in postoperative neuroinflammation are the putative targets for future therapeutic interventions that are efficacious and do not interfere with the surgical patient's healing process.

Accessible Summary: What is known on the subject?: Emergency departments (ED) are key settings to support and manage suicidal crisis; thus, ED staff are often the first point of contact for people in suicidal crisis. Despite this, some ED staff receive little training and/or education on how to best support such patients. What the paper adds to existing knowledge: Previous research focuses on one staffing role (e.g. triage nurses) whereas this paper includes staff working across the ED pathway. Administrative staff have often been excluded from research, despite representing a key part of the clinical pathway and being a person's initial contact with the ED.Overall findings demonstrate that staff experience a lack of confidence, training and burnout due to regularly supporting people in suicidal crisis. Staff also perceive there to be a negative ED culture, which often leads to poor attitudes towards suicidal crisis. The main challenges reported are an increase in working pressures, unavailability of resources and staff retention.Findings build upon previous research to highlight key challenges different staff face along the clinical pathway and the implications this can have on a patient's journey and follow‐up care provided. What are the implications for practice?: Findings are of particular importance and relevance to ED managers, and more broadly NHS England. Negative ED culture, poor staff attitudes and confidence can have a detrimental impact on both staff health and wellbeing, as well as a patient's journey throughout the ED, resulting in repeat presentations and absconding as appropriate support is not received.Policymakers need to consider staff burnout and lack of resources in mental health care strategies, and training programmes should be developed to improve culture and confidence among ED staff and managers to improve care for people attending EDs in suicidal crisis. Introduction: Emergency departments (EDs) are often the first point of contact for people in suicidal crisis. Yet, previous work has tended to focus on only one type of staffing role, failing to account for different staff perspectives along the clinical pathway. Aims: To explore and synthesise the perspectives of ED administrative (i.e. receptionists), medical (triage nurses) and mental health staff (liaison psychiatrists) working with people presenting in suicidal crisis. Method: Qualitative study guided by thematic analysis of semi‐structured interviews with 23 ED staff across six EDs in Cheshire and Merseyside, England. Results: Findings demonstrate that staff experience a lack of confidence, training and burnout due to regularly supporting people in suicidal crisis. The main challenges reported are an increase in working pressures, unavailability of resources and staff retention. Discussion: Staff felt unequipped to deal with suicide‐related presentations. Organisational support is perceived to be lacking, with increased staffing pressures and poor service availability. This lack of support was linked to job dissatisfaction. Implications for Practice: Findings are of particular relevance to individual EDs and NHS England. Addressing the challenges staff are reporting can have positive implications for staff wellbeing, as well as a patient's experience and journey throughout the ED. [ABSTRACT FROM AUTHOR]

Determine current vision care pathways and practices for stroke survivors in Australia and internationally, focusing on identifying reoccurring gaps in these pathways and unmet care needs. A scoping narrative review was conducted to identify literature related to post-stroke vision care practices and perspectives of patients and health professionals. A total of 16193 articles were retrieved and 28 deemed eligible for inclusion. Six were Australian, 14 from the UK, four from the USA, and four from within Europe. Post-stroke vision care is largely unstandardized, with substantial inconsistency in the use of vision care protocols, who executes them and at what point in post-stroke care they are utilised. Health professionals and stroke survivors expressed that unmet care needs were primarily a result of lack of education and awareness regarding post-stroke eye problems. Other gaps in care pathways related to the timing of vision assessment, provision of ongoing support, and the integration of eye-care specialists into the stroke team. Further research is needed into current Australian post-stroke vision care to accurately assess whether the needs of stroke survivors are being met. Available evidence indicates that in Australia, there is a requirement for well-defined protocols for vision screening, education, management, and referral of stroke survivors. Post-stroke vision care in Australia is unstandardised, which may cause inequities in vision care provision to Australian stroke survivors in different regions and/or care facilities. Education and training pertaining to stroke-related vision conditions for stroke healthcare professionals and the inclusion of eye-care professionals in stroke care teams is likely to improve gaps in care practice/pathways identified in the current evidence base. Management of stroke-related visual conditions should be inclusive of detailed information provision that is specific to the patients condition(s) and circumstances, as well as ongoing, long-term management strategies/support services to better aid stroke survivor"s reintegration into the community. [ABSTRACT FROM AUTHOR]

Clinical pathways are structured multidisciplinary care plans used by treatment providers to detail essential steps in the care of patients based on assessment of their current health care needs and motivation and commitment for treatment. Reducing unnecessary variations in care and streamlining treatment processes in mental health settings may promote efficiency and help support quality improvement efforts. (Rotter et al., 2019) In this article we will describe the development of clinical pathways, coined Patient Centered Clinical Tracks (PCCT) in an outpatient community mental health clinic in an academic medical center in New York City. PCCT is comprised of six different clinical pathways that include: Medication & Engagement, Supportive Therapy, Dialectal-Behavior Therapy, Cognitive-Behavioral Therapy/Acceptance Commitment-Therapy, Relational Therapy and THRIVE (a Trauma Specialty Program). We will present the six Clinical Tracks and describe the early implementation of this model. We will explore how this programmatic infrastructure can connect evidence to practice and address multiple systemic challenges faced in a community mental health setting with a strong emphasis on training. [ABSTRACT FROM AUTHOR]

The article focuses on the conceptual framework of actor-network theory, emphasizing the interconnectedness of humans and non-humans in shaping mental health effects. Topics include theory's development by researchers aiming to highlight non-human agency in scientific inquiry, its application in mental health nursing to understand the complexities of health effects, and its potential uses in research and practice to sensitize healthcare workers to human-non-human interactions.

BackgroundHealth equity is defined as the absence of unjust and avoidable disparities in access to healthcare, quality of care, or health outcomes. The World Health Organization (WHO) has developed a conceptual framework that outlines the main causes of health inequalities and how these contribute to health inequities within a population. Despite the WHO implementing health equity policies to ensure accessibility and quality of healthcare services, disparities persist in the management of patients suffering from low back pain (LBP). The objective of this study was to review the existing evidence on the impact of health inequities on the care trajectories and treatments provided to individuals with LBP.MethodsA narrative review was performed, which included a literature search without language and study design restrictions in MEDLINE Ovid database, from January 1, 2000, to May 15, 2023. Search terms included free-text words for the key concepts of “low back pain,” “health inequities,” “care pathways,” and “sociodemographic factors.”ResultsStudies have revealed a statistically significant association between the prevalence of consultations for LBP and increasing age. Additionally, a significant association between healthcare utilization and gender was found, revealing that women were more likely to seek medical attention for LBP compared to men. Furthermore, notable disparities related to race and ethnicity were identified, more specifically in opioid prescriptions, spinal surgery recommendations, and access to complementary and alternative medical approaches for LBP. A cross-sectional analysis found that non-Hispanic White individuals with chronic LBP were more likely to be prescribed one or more pharmacological treatments. Lower socioeconomic status and level of education, as well as living in lower-income areas were also found to be associated with greater risks of receiving non-guideline concordant care, including opioid and MRI prescriptions, before undergoing any conservative treatments.ConclusionPersistent inequalities related to sociodemographic determinants significantly influence access to care and care pathways of patients suffering from LBP, underscoring the need for additional measures to achieve equitable health outcomes. Efforts are needed to better understand the needs and expectations of patients suffering from LBP and how their individual characteristics may affect their utilization of healthcare services.

Abstract Background The number of older people in prison is growing. As a result, there will also be more prisoners suffering from dementia. The support and management of this population is likely to present multiple challenges to the prison system. Objectives To examine the published literature on the care and supervision of people living in prison with dementia and on transitioning into the community; to identify good practice and recommendations that might inform the development of prison dementia care pathways. Methods A scoping review methodology was adopted with reporting guided by the PRISMA extension for scoping reviews checklist and explanation. Results Sixty-seven papers were included. Most of these were from high income countries, with the majority from the United Kingdom (n = 34), followed by the United States (n = 15), and Australia (n = 12). One further paper was from India. Discussion The literature indicated that there were difficulties across the prison system for people with dementia along the pathway from reception to release and resettlement. These touched upon all aspects of prison life and its environment, including health and social care. A lack of resources and national and regional policies were identified as important barriers, although a number of solutions were also identified in the literature, including the development of locally tailored policies and increased collaboration with the voluntary sector. Conclusion To our knowledge, this is the most comprehensive and inclusive review of the literature on dementia care pathways in prison to date. It has identified a number of important areas of concern and opportunities for future research across the prison system, and its operations. This will hopefully lead to the identification or adaptation of interventions to be implemented and evaluated, and facilitate the development of dementia care pathways in prisons.

Background: Approximately 37 million individuals in the United States (US) have chronic kidney disease (CKD). Patients with CKD have a substantial morbidity and mortality, which contributes to a huge economic burden to the healthcare system. A limited number of clinical pathways or defined workflows exist for CKD care delivery in the US, primarily due to a lower prioritization of CKD care within health systems compared with other areas (e.g., cardiovascular disease [CVD], cancer screening). CKD is a public health crisis and by the year 2040, CKD will become the fifth leading cause of years of life lost. It is therefore critical to address these challenges to improve outcomes in patients with CKD. Methods: The CKD Leaders Network conducted a virtual, 3 h, multidisciplinary roundtable discussion with eight subject-matter experts to better understand key factors impacting CKD care delivery and barriers across the US. A premeeting survey identified topics for discussion covering the screening, diagnosis, risk stratification, and management of CKD across the care continuum. Findings from this roundtable are summarized and presented herein. Results: Universal challenges exist across health systems, including a lack of awareness amongst providers and patients, constrained care team bandwidth, inadequate financial incentives for early CKD identification, non-standardized diagnostic classification and triage processes, and non-centralized patient information. Proposed solutions include highlighting immediate and long-term financial implications linked with failure to identify and address at-risk individuals, identifying and managing early-stage CKD, enhancing efforts to support guideline-based education for providers and patients, and capitalizing on next-generation solutions. Conclusions: Payers and other industry stakeholders have opportunities to contribute to optimal CKD care delivery. Beyond addressing the inadequacies that currently exist, actionable tactics can be implemented into clinical practice to improve clinical outcomes in patients at risk for or diagnosed with CKD in the US. [ABSTRACT FROM AUTHOR]

Aim: To explore the factors that affect the experiences of autistic patients in the hospital setting. Design: A scoping review. Data Sources: A systematic literature search using the databases CINAHL, Medline and Google Scholar was undertaken in September 2021 and updated in January 2023. This review is based on the methodological framework of Arksey and O'Malley (International Journal of Social Research Methodology, 8(1):19-32, 2005), which was further refined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. Results: Autistic patients, as well as their families and healthcare staff, face several barriers that can impact their healthcare experiences within hospital settings. Of 211 articles screened, 30 were eligible and included. Through our review, we identified two main themes. The first theme, 'challenges to hospital experiences', includes four subthemes: (1) communication, (2) a mismatch between the needs for autistic patients and the hospital environment, (3) challenges related to parents' experiences and (4) challenges related to hospital systems. The second theme, 'facilitators that improve hospital experiences', includes three sub-themes: (1) provision of care pathways, (2) partnership between parents and experts and (3) facilitators to improve hospital systems. By understanding these themes, we can work to address the barriers that autistic patients and their families face, while leveraging the facilitators to improve their hospital experiences. Conclusion: It is critical to understand the experiences of autistic patients in the hospital setting because they present a substantial risk of hospital admission due to their associated acute to chronic health conditions. Additionally, nurses and other medical staff must understand the unique hospital experiences and challenges of autistic patients to improve care and facilitate better hospital experiences. This review further highlights the crucial need to adopt a collaborative and inclusive approach between autistic patients, their families and healthcare staff. To achieve this, co-design initiatives that incorporate the perspectives and lived experiences of the autistic community are necessary. By placing autistic voices at the forefront of these initiatives, it is hoped that changes are meaningful, relevant and can be sustained. Impact: Understanding the unique hospital experiences and challenges of autistic patients can improve their quality of life and well- being by reducing stress and anxiety during hospitalization, leading to better health outcomes and potentially shorter hospital stays. It can also promote a more positive view of healthcare among autistic individuals, encouraging them to seek medical care when needed and have broader societal impacts such as reducing healthcare costs and improving the overall health and well-being of the population. Autistic patients present a substantial risk of hospital admission due to their associated acute to chronic conditions. Nurses and other medical staff must understand the unique hospital experiences and challenges of autistic patients to improve care and facilitate better hospital experiences. Patient or Public Contribution: No patient or public contribution. [ABSTRACT FROM AUTHOR]

Aim: Standardised enteral nutrition protocols are recommended in critical care, however their use and safety are not well described in other inpatient populations. This mixed methods study reports on the use and safety of enteral nutrition protocols for non‐critically ill adults. Methods: A scoping review of published literature was conducted. In addition a retrospective audit of practice at an Australian tertiary teaching hospital with an existing hospital‐wide standardised enteral nutrition protocol was performed. Data on use, safety and adequacy of enteral nutrition prescription were collected from medical records for patients receiving enteral nutrition on acute wards (January–March 2020). Results: Screening of 9298 records yielded six primary research articles. Studies were generally low quality. Published literature suggested that protocols may reduce time to enteral nutrition initiation and goal rate, and improve adequacy of nutrition provision. No adverse outcomes were reported. From the local audit of practice (105 admissions, 98 patients), enteral nutrition commencement was timely (median 0 (IQR 0–1) days from request; goal rate: median 1 (IQR 0–2) days from commencement and adequate (nil underfeeding), without prior dietitian review in 82% of cases. Enteral nutrition was commenced per protocol in 61% of instances. No adverse events, including refeeding syndrome, were observed. Conclusions: Most inpatients requiring enteral nutrition can be safely and adequately managed on enteral nutrition protocols. Evaluation of protocols outside of the critical care setting remains a gap in the literature. Standardised enteral nutrition protocols may improve delivery of nutrition to patients, whilst allowing dietitians to focus on those with specialised nutrition support needs. [ABSTRACT FROM AUTHOR]

Objectives: To assess the immediate and six-month follow-up effects of medical education simultaneously provided by a practitioner and a science teacher on middle school students regarding self-medication and knowledge of the healthcare system. Methods: Two groups were constituted: the learning group (L group), with students receiving an interactive medical education, and the control group (C group), which included students without medical education. Both groups were evaluated by using a six-multiple choice question (MCQ) evaluation form: three times for L group - just before the medical workshop (T0), immediately after the medical workshop (T1) and at six-month follow-up after the medical workshop (T2) - and only the evaluation at T0 for students in C group. Results: In L group (n=219), medical education improved all results of the evaluations related to self-medication skills (p<0.001) and knowledge of the healthcare medical system (p<0.001). Students retained their knowledge over time as no significant gap has been identified between T1 and T2 evaluations. Age, gender, grade and students' level did not have any impact on the results of L group. Students in L group had equivalent results to those in the C group (n=195) at T0 but the results increased at T1 (p<0.001) and T2 (p<0.001). Conclusion: Interactive medical education in middle school co-animated by a medical practitioner and a natural science teacher improves long-term teenagers' awareness of the current public health challenges. [ABSTRACT FROM AUTHOR]

Abstract Background Rapid diagnostic testing may support improved treatment of COVID patients. Understanding COVID testing and care pathways is important for assessing the impact and cost-effectiveness of testing in the real world, yet there is limited information on these pathways in low-and-middle income countries (LMICs). We therefore undertook an expert consultation to better understand testing policies and practices, clinical screening, the profile of patients seeking testing or care, linkage to care after testing, treatment, lessons learnt and expected changes in 2023. Methods We organized a qualitative consultation with ten experts from seven LMICs (India, Indonesia, Malawi, Nigeria, Peru, South Africa, and Zimbabwe) identified through purposive sampling. We conducted structured interviews during six regional consultations, and undertook a thematic analysis of responses. Results Participants reported that, after initial efforts to scale-up testing, the policy priority given to COVID testing has declined. Comorbidities putting patients at heightened risk (e.g., diabetes) mainly relied on self-identification. The decision to test following clinical screening was highly context-/location-specific, often dictated by local epidemiology and test availability. When rapid diagnostic tests were available, public sector healthcare providers tended to rely on them for diagnosis (alongside PCR for Asian/Latin American participants), while private sector providers predominantly used polymerase chain reaction (PCR) tests. Positive test results were generally taken at ‘face value’ by clinicians, although negative tests with a high index of suspicion may be confirmed with PCR. However, even with a positive result, patients were not always linked to care in a timely manner because of reluctance to receiving care or delays in returning to care centres upon clinical deterioration. Countries often lacked multiple components of the range of therapeutics advised in WHO guidelines: notably so for oral antivirals designed for high-risk mild patients. Severely ill patients mostly received corticosteroids and, in higher-resourced settings, tocilizumab. Conclusions Testing does not always prompt enhanced care, due to reluctance on the part of patients and limited therapeutic availability within clinical settings. Any analysis of the impact or cost-effectiveness of testing policies post pandemic needs to either consider investment in optimal treatment pathways or constrain estimates of benefits based on actual practice.

Aims: The aim of this study was to describe the current pathways of care for patients with a fracture of the hip in five low- and middle-income countries (LMIC) in South Asia (Nepal and Sri Lanka) and Southeast Asia (Malaysia, Thailand, and the Philippines). Methods: The World Health Organization Service Availability and Readiness Assessment tool was used to collect data on the care of hip fractures in Malaysia, Thailand, the Philippines, Sri Lanka, and Nepal. Respondents were asked to provide details about the current pathway of care for patients with hip fracture, including pre-hospital transport, time to admission, time to surgery, and time to weightbearing, along with healthcare professionals involved at different stages of care, information on discharge, and patient follow-up. Results: Responses were received from 98 representative hospitals across the five countries. Most hospitals were publicly funded. There was consistency in clinical pathways of care within country, but considerable variation between countries. Patients mostly travel to hospital via ambulance (both publicly- and privately-funded) or private transport, with only half arriving at hospital within 12 hours of their injury. Access to surgery was variable and time to surgery ranged between one day and more than five days. The majority of hospitals mobilized patients on the first or second day after surgery, but there was notable variation in postoperative weightbearing protocols. Senior medical input was variable and specialist orthogeriatric expertise was unavailable in most hospitals. Conclusion: This study provides the first step in mapping care pathways for patients with hip fracture in LMIC in South Asia. The previous lack of data in these countries hampers efforts to identify quality standards (key performance indicators) that are relevant to each different healthcare system. Cite this article: Bone Jt Open 2023;4(9):676–681.

Abstract Background Care pathways are increasingly being used to enhance the quality of care and optimize the use of resources for health care. Nevertheless, recommendations regarding the sequence of care are mostly based on consensus-based decisions as there is a lack of evidence on effective treatment sequences. In a real-world setting, classical statistical tools were insufficient to consider a phenomenon with such high variability adequately and have to be integrated with novel data mining techniques suitable for identifying patterns in complex data structures. Data-driven techniques can potentially support empirically identifying effective care sequences by extracting them from data collected routinely. The purpose of this study is to perform a state sequence analysis (SSA) to identify different patterns of treatment and to asses whether sequence analysis may be a useful tool for profiling patients according to the treatment pattern. Methods The clinical application that motivated the study of this method concerns the mental health field. In fact, the care pathways of patients affected by severe mental disorders often do not correspond to the standards required by the guidelines in this field. In particular, we analyzed patients with schizophrenic disorders (i.e., schizophrenia, schizotypal or delusional disorders) using administrative data from 2015 to 2018 from Lombardy Region. This methodology considers the patient’s therapeutic path as a conceptual unit, composed of a succession of different states, and we show how SSA can be used to describe longitudinal patient status. Results We define the states to be the weekly coverage of different treatments (psychiatric visits, psychosocial interventions, and anti-psychotic drugs), and we use the longest common subsequences (dis)similarity measure to compare and cluster the sequences. We obtained three different clusters with very different patterns of treatments. Conclusions This kind of information, such as common patterns of care that allowed us to risk profile patients, can provide health policymakers an opportunity to plan optimum and individualized patient care by allocating appropriate resources, analyzing trends in the health status of a population, and finding the risk factors that can be leveraged to prevent the decline of mental health status at the population level.

Abstract Aims Cancer is one of the main causes of death in persons with severe mental illness (SMI). Although their cancer incidence is similar, or sometimes even potentially lower compared to the general population, their cancer mortality remains higher. The role of healthcare provision and care equity in this mortality is increasingly being addressed in research, but available studies are limited in their scope. In this context, our aim was to compare colorectal cancer (CRC) care pathways from screening to end-of-life care in patients with and without pre-existing SMI on a national scale. Methods This research leverages real-world data from the French national health claims database, covering the entire population, to assess cancer screening, diagnosis, treatment and post-treatment follow-up as well as quality of care (QOC) pathways among patients with incident CRC in 2015–2018, considering whether they had pre-existing SMI. We matched patients with SMI with three patients without – on age, sex, region of residence, year of cancer incidence and cancer type and location at presentation – as well as nationally established quality of CRC care indicators and regression models adjusting for relevant socio-economic, clinical and care provider-related covariates. Results Among patients with incident CRC, 1,532 individuals with pre-existing SMI were matched with individuals without SMI. After adjusting for covariates, both colon and rectal cancer patients with SMI were less likely to participate in the national CRC screening programme and to receive advanced diagnostic examinations (e.g., colonoscopies and several complementary diagnostic examinations). They also had lower odds of receiving combined treatments (e.g., neoadjuvant chemotherapy, radiotherapy and excision) and of having access to targeted therapy or capecitabine but higher odds for invasive care (e.g., stoma). Colon cancer patients with SMI were also more likely to have no treatment at all, and rectal cancer patients with SMI were less likely to receive post-treatment follow-up. Suboptimal QOC was observed for both groups of patients, but to a higher extent for patients with SMI, with statistically significant differences for indicators focusing on diagnosis and post-treatment follow-up. Conclusions Our findings reveal discrepancies across the care continuum of CRC between individuals with and without SMI and provide initial avenues on where to focus future efforts to address them, notably at the entry and exit stages of cancer care pathways, while calling for further research on the mechanisms preventing equity of physical healthcare for individuals with SMI.

The increasing prevalence of allergic disease has resulted in the recognition of allergy as a global public health concern. Yet health services worldwide appear to be ill-equipped to deliver high-quality allergy care. Clinical guidelines have been developed to describe what high-quality care looks like for most allergic diseases. However, allergy guidelines do not describe how the delivery of such care is organised across clinicians and provider organisations with varying degrees of access to allergy expertise and clinical resources. In this article, we describe how care pathways can be used to improve the organisation and delivery of allergy care in accordance with the characteristics of allergic disease and local constraints in the health service. We then describe how quality-improvement methods can support the successful realisation of allergy care pathways in practice. Realising care pathways involves a highly complex process of changing the way care is practised and organised. This could involve developing a new service, clinical training or other interventions. Qualityimprovement methods were developed as a guide to navigate and support the process of change and improvement. [ABSTRACT FROM AUTHOR]

Background: Rapid diagnostic testing may support improved treatment of COVID patients. Understanding COVID testing and care pathways is important for assessing the impact and cost-effectiveness of testing in the real world, yet there is limited information on these pathways in low-and-middle income countries (LMICs). We therefore undertook an expert consultation to better understand testing policies and practices, clinical screening, the profile of patients seeking testing or care, linkage to care after testing, treatment, lessons learnt and expected changes in 2023. Methods: We organized a qualitative consultation with ten experts from seven LMICs (India, Indonesia, Malawi, Nigeria, Peru, South Africa, and Zimbabwe) identified through purposive sampling. We conducted structured interviews during six regional consultations, and undertook a thematic analysis of responses. Results: Participants reported that, after initial efforts to scale-up testing, the policy priority given to COVID testing has declined. Comorbidities putting patients at heightened risk (e.g., diabetes) mainly relied on self-identification. The decision to test following clinical screening was highly context-/location-specific, often dictated by local epidemiology and test availability. When rapid diagnostic tests were available, public sector healthcare providers tended to rely on them for diagnosis (alongside PCR for Asian/Latin American participants), while private sector providers predominantly used polymerase chain reaction (PCR) tests. Positive test results were generally taken at 'face value' by clinicians, although negative tests with a high index of suspicion may be confirmed with PCR. However, even with a positive result, patients were not always linked to care in a timely manner because of reluctance to receiving care or delays in returning to care centres upon clinical deterioration. Countries often lacked multiple components of the range of therapeutics advised in WHO guidelines: notably so for oral antivirals designed for high-risk mild patients. Severely ill patients mostly received corticosteroids and, in higher-resourced settings, tocilizumab. Conclusions: Testing does not always prompt enhanced care, due to reluctance on the part of patients and limited therapeutic availability within clinical settings. Any analysis of the impact or cost-effectiveness of testing policies post pandemic needs to either consider investment in optimal treatment pathways or constrain estimates of benefits based on actual practice. [ABSTRACT FROM AUTHOR]

Numerous calls at national and international level are leading some countries to seek to redesign the provision of healthcare and services. Care pathways have the potential to improve outcomes by providing a mechanism to coordinate care and reduce fragmentation and ultimately costs. However, their implementation still shows variable results, resulting in them being considered as complex interventions in complex systems. By mobilizing an emerging approach combining action research and grounded theory methodology, we conducted a pilot project on care pathways. We used a strongly inductive process, to mobilize comparison and continuous theoretical sampling to produce theories. Forty-two interviews were conducted, and participant observations were made throughout the project, including 60 participant observations at meetings, workshops and field observations. The investigators kept logbooks and recorded field notes. Thematic analysis was used with an inductive approach. The present model explains the factors that positively or negatively influence the implementation of innovations in care pathways. The model represents interactions between facilitating factors, favourable conditions for the emergence of innovation adoption, implementation process enablers and challenges or barriers including those related specifically to the local context. What seems to be totally new is the embodiment of the mobilizing shared objective of active patient-partner participation in decision-making, data collection and analysis and solution building. This allows, in our opinion, to transcend professional perspectives for the benefit of patient-oriented results. Finally, the pilot project has created expectations in terms of spread and scaling. Future research on care pathway implementation should go further in the evaluation of the multifactorial impacts and develop a methodological framework of care pathway implementation, as the only existing proposition seems limited. Furthermore, from a social science perspective, it would be interesting to analyse the modes of social valuation of the different actors to understand what allows the transformation of collective action. [ABSTRACT FROM AUTHOR]

Secure mental health services aim to assess and treat mentally disordered offenders, where a patients care pathway involves their movement from service to service on an individual journey towards recovery. Research has attempted to understand the relationship between psychosis and violence for mentally disordered offenders. From this empirical evidence base a tripartite typology has emerged. Three subgroups have been categorised as (i) schizophrenia preceded by conduct disorder (SZ+CD), (ii) offenders with schizophrenia who begin offending at illness onset (SZ+AS), and (iii) offenders with schizophrenia (SZ). This study aimed to examine differences in care pathways between subgroups. The sample consisted of 77 male patients admitted to low- and medium-secure care. The subgroup of patients was determined from data collected from health records. The analysis examined the differences in patient care pathways. The results demonstrated differences in subgroup pathways to, within and from secure services. The SZ+CD subgroup had a higher number of placements used, were more likely to transition between the same level of security, and had an increased use of the private sector. The SZ+AS subgroup was significantly more likely to use intensive care and less likely to use high secure services. Examining care pathways of mentally disordered offenders will ensure a more evidence-based approach to the configuration and operationalisation of services, help guide policymakers and hopefully improve patient care. [ABSTRACT FROM AUTHOR]

Lumbar discectomy is a common procedure following which emergency department (ED) visits may occur. Although many quality improvement initiatives target reemissions, ED visits may be more common, be a marker of quality of care, affect patient satisfaction, and contribute to health-care resource utilization and costs. To analyze the timing and risk factors predicting ED utilization following lumbar discectomy and thereby facilitate better-targeted risk reduction. Retrospective database review of the 2010 to April 30th, 2021, M157Ortho PearlDiver dataset. Single-level lumbar laminotomy/discectomy between 2010 and April 30th, 2021, in the PearlDiver M157Ortho dataset. Functional measures—ED utilization in the 90 days following lumbar discectomy, patient-level predictors for ED utilization, and number and type of reoperations performed in the 90 days following lumbar discectomy. Lumbar laminotomies/discectomies were identified. Patients were excluded if additional procedures were performed or if there was not 90-day follow-up in the dataset. Patient factors were extracted, including age, sex, Elixhauser comorbidity index (ECI), region of the country in which their procedure was performed (Midwest, Northeast, South, West), and patient insurance plan (Commercial, Medicaid, Medicare). The incidence, timing, and frequency of ED utilization within 90 days of lumbar discectomy were then determined. Cohort average weekly ED utilization at 1-year postoperatively was calculated as a baseline for reference. Patient factors predictive of postoperative ED utilization were then determined with univariate and multivariate analyses. Primary diagnoses for ED visits were also categorized. Patients who underwent reoperation for complications related to lumbar discectomy following ED visits were determined, and types of reoperation procedures were characterized. Of 281,103 lumbar discectomy patients identified, ED visits within 90 days of surgery were identified for 28,632 (10.2%). Of note, 40.4% of these ED visits occurred in the first 2 postoperative weeks. Multivariate analysis revealed several independent predictors of ED utilization following lumbar discectomy, including: younger age (odds ratio [OR] 1.21 per decade decrease), female sex (OR 1.12 relative to male), higher ECI (OR 1.42 per 2-point increase), having surgery performed in the Northeast, Midwest, or West United States (OR 1.05, 1.17, and 1.13, respectively, relative to South), and Medicaid coverage (OR 1.89 relative to Medicare). Forty-three percent of ED visits were surgical site related, of which surgical site pain predominated at 34.2% of overall reasons. Of patients who visited the ED, 943 (3.3%) underwent reoperation in the subsequent 2 weeks. Laminectomy with nerve root decompression was the most performed reoperation (30.9%), followed by incision and drainage (22.5%), posterior nonsegmental instrumentation (10.3%), laminectomy facetectomy and foraminotomy (9.97%), repair of dural/CSF leak or pseudomeningocele with laminectomy (9.3%), repair of dural/CSF leak not requiring laminectomy (8.9%), arthrodesis (4.3%), and posterior segmental instrumentation (3.9%). Following lumbar discectomy, over 1 in 10 patients were found to visit the ED in the 90 days following their surgery, most commonly in the first 2 postoperative weeks. Specific patient characteristics were associated with such ED visits, with the most common primary diagnoses among ED visitors being surgical site pain. About 3.3% of patients who visited the ED underwent reoperation in the subsequent 2 weeks. Through identification of the timing, risk factors, primary reasons for, and risk of reoperation following ED utilization in the 90-day period after lumbar discectomy, care pathways can be modified to improve patient satisfaction, outcomes, and reduce excess health-care expenditures. [ABSTRACT FROM AUTHOR]

Background/Aims: Embedded pragmatic clinical trials are increasingly recommended for non-pharmacological pain care research due to their focus on examining intervention effectiveness within real-world settings. Engagement with patients, health care providers, and other partners is essential, yet there is limited guidance for how to use engagement to meaningfully inform the design of interventions to be tested in pain-related pragmatic clinical trials. This manuscript aims to describe the process and impacts of partner input on the design of two interventions (care pathways) for low back pain currently being tested in an embedded pragmatic trial in the Veterans Affairs health care system. Methods: Sequential cohort design for intervention development was followed. Engagement activities were conducted with 25 participants between November 2017 and June 2018. Participants included representatives from multiple groups: clinicians, administrative leadership, patients, and caregivers. Results: Partner feedback led to several changes in each of the care pathways to improve patient experience and usability. Major changes to the sequenced care pathway included transitioning from telephone-based delivery to a flexible telehealth model, increased specificity about pain modulation activities, and reduction of physical therapy visits. Major changes to the pain navigator pathway included transitioning from a traditional stepped care model to one that offers care in a feedback loop, increased flexibility regarding pain navigator provider type, and increased specificity for patient discharge criteria. Centering patient experience emerged as a key consideration from all partner groups. Conclusion: Diverse input is important to consider before implementing new interventions in embedded pragmatic trials. Partner engagement can increase acceptability of new care pathways to patients and providers and enhance uptake of effective interventions by health systems. Trial registration: NCT#04411420. Registered on 2 June 2020. [ABSTRACT FROM AUTHOR]