Staff and patient experience of the implementation and delivery of a virtual health care home monitoring service for COVID-19 in Melbourne, Australia

BACKGROUND

Provision of virtual health care (VHC) home monitoring for patients who are experiencing mild to moderate COVID-19 illness is emerging as a central strategy for reducing pressure on acute health systems. Understanding the enablers and challenges in implementation and delivery of these programs is important for future implementation and re-design. The aim of this study was to explore the perspectives of staff involved with the implementation and delivery, and the experience of patients managed by, a VHC monitoring service in Melbourne, Australia during the COVID-19 pandemic.

METHODS

A descriptive qualitative approach informed by naturalist inquiry was used. Staff interviews were analysed using the Consolidated Framework for Implementation Research (CFIR). Patient experience was captured using a survey and descriptive statistics were used to describe categorical responses while content analysis was used to analyse free text responses as they related to the CFIR. Finally, data from the interviews and patient experience were triangulated to see if patient experience validated data from staff interviews.

RESULTS

All 15 staff were interviewed, and 271 patients were surveyed (42%). A total of four final overarching themes emerged: service implementation enablers, service delivery benefits for patients, fragmentation of care, and workforce strengths. 19 subthemes aligned with 18 CFIR constructs from staff and patient data.

CONCLUSION

Rapid implementation was enabled through shared resources, dividing implementation tasks between senior personnel, engaging furloughed healthcare staff in design and delivery, and having a flexible approach that allowed for ongoing improvements. Benefits for patients included early identification of COVID-19 deterioration, as well as provision of accurate and trustworthy information to isolate safely at home. The main challenges were the multiple agencies involved in patient monitoring, which may be addressed in the future by attributing responsibility for monitoring to a single agency.

1062 Are CT-KUB Requests Adequately Completed by Urologists in Emergency Settings?

Aim

Imaging requests are an essential communication tool between urologists and radiologists. Poorly completed request forms, especially in acute settings, directly translates to substandard patient care. We aimed to evaluate and improve our request completion practice in emergency settings.

Method

40 randomly selected CT-KUB images were reviewed to assess the completion of clinical background, question, patient data, location, and requester data. A multiple cycle audit followed by minor intra-departmental interventions were carried out over ten months to evaluate compliance. In December 2019, 55% and 52.5% of the requests lacked a good clinical history and question, respectively. The remaining three domains achieved the target of 100%. Subsequently, the literature and the audit data were shared and discussed, and a verbal agreement was made to improve practice.

Result

A re-audit revealed a 22.5% and 2.5% improvement in providing sufficient clinical background and questions. Findings were presented at an informal setting, and feedback was obtained on improving compliance. Simple posters or notices and occasional reminders were found as acceptable approaches. Following the implementation of feedback and orientation for joining junior doctors, a third audit cycle showed a significant improvement in compliance with 90% and 82.5%. A final cycle to assess the maintenance improvements in background and question provision was at a high of 97.5% and 90%.

Conclusions

CT-KUB request completion is essential in emergency settings to ensure optimal patient care. Improving compliance can be achieved using small interventions catered to the department, such as peer-to-peer discussions, reminder posters, and orientations.

Licorice-induced apparent mineralocorticoid excess causing persistent hypertension and hypokalemia

Chronic ingestion of licorice is known to cause numerous metabolic and electrolyte disturbances. Severe hyponatremia, hypertension, and hypokalemia as well as metabolic alkalosis are amongst the most common consequences of chronic ingestion resulting in an apparent mineralocorticoid excess (AME). Treatment predominantly consists of cessation of licorice ingestion, potassium replenishment and aldosterone antagonists. Given the potentially lethal effects of chronic licorice ingestion, clinicians should be made aware of the presentation of AME and the proper management. We present the rare case of a 62-year-old male with licorice-induced apparent mineralocorticoid excess secondary to excessive licorice tea intake. Initial presentation included severe hypokalemia of 2.2mmol/L and hypertension of 180/110mmHg, while eunatremic (Na, 144meq/L).

A clinical trial to study the effect of adding cis-retinoic acid during and after conventional treatment for pediatric neuroblastoma patient

10057

Background: Neuroblastoma is predominantly a tumor of early childhood, with two thirds of the cases presenting in children younger than 5 years. Cis-retinoic acid has been used as maintenance therapy for treatment of advanced neuroblastoma after BMT. Patients who received cis-retinoic acid had significantly better 3-year event-free survival than patients receiving no maintenance therapy. However, there is no data available about usingcis-retinoic acid during induction phase of chemotherapy. The aim of this study is to evaluate the efficacy of cis-retinoic acid when used in combination with conventional chemotherapy in pediatric patient who is newly diagnosed with locally advanced neuroblastoma. Methods: Seventeen newly diagnosed children with locally advanced neuroblastoma who is candidate to receive chemotherapy were also received cis-retinoic acid starting at a dose of 160 /m2 day (day 2–15 of chemotherapy) first the 3 patients, 20% dose reduction were allowed if toxicity occurred in first cohort of patient. . Patients were giving the drugs for at least 4 cycles. RT-PCR analysis of several related genes was done from tumor, sample after treatment. Results: Median age 2.4. Male:Female ratio was 1.4:1. Patients were stage III, IV (70%), II (30%). 88% of patients were presented with abdominal mass .Most patient received at least 6 cycles of OPEC/OJEC regimen. N Myc was done to 12 of patients. Median follow up was 6 months. Maximum tolerated dose were 130mg/m2, response was seen as CR 30%VGR 40, PR 12%, and PD 18%. Median event free survival was 12 months. Toxicity: Hypercalcemia mucositis, rash, and elevated liver enzymes were the main dose limiting effect of cis-retinoic acid. Preliminary collaborative analysis showed that down regulation of N-MYC is related to response rate. Conclusions: Cis-retinoic acid at dose 130mg/m2 is a well tolerated drug with chemotherapy. Response to treatment is better than historical control. Randomized phase III trial is warranted.

No significant financial relationships to disclose.

In vitro contractile responses of detrusor to carbachol and neurokinin A, in children with recurrent urinary tract infection or day wetting

OBJECTIVE

To investigate whether a history of recurrent urinary tract infection (UTI) and/or the presence of day-wetting/urge symptoms might influence the contractile responses to the cholinergic agonist carbachol or to the sensory neuropeptide neurokinin A (NKA) in the urinary bladder in children.

PATIENTS AND METHODS

Small detrusor strips were taken from the margin of the cystotomy incision of the bladder dome during surgery to correct vesico-ureteric reflux (VUR) in 62 children (aged 4 months to 12 years) or for unrelated bladder conditions in five controls (aged 3 months to 13 years). Concentration-response curves to carbachol and NKA were constructed using organ-bath techniques, and results compared for age, sex, weight of the detrusor strip, UTI history or day-wetting syndrome.

RESULTS

The contractile responses to NKA were no different for any of the features investigated. The contractile response to carbachol and NKA in detrusor from control and VUR patients was not significantly different. The children with a history of UTI were significantly older than those without. The contractility in response to carbachol was greater in older girls (aged 4-12 years) than younger girls (< 4 years) and than in all boys (< 4 years and 4-12 years; ANOVA P = 0.013). The mean (SEM) maximum contractile response to carbachol in the group of 20 young children (4-30 months) with previous UTI was 3.0 (0.3) g, whereas the maximum response in the age-matched group of 11 without UTI was 1.8 (0.3) g (P = 0.046). There were no significant differences in maximum responses between those with day-wetting and those without (aged > 4 years), although there was a significant difference in pD2 value, at 6.19 (0.13) and 5.58 (0.14), respectively (P = 0.018).

CONCLUSION

Carbachol produced a larger contractile response in detrusor from children with a history of UTI than from those without, indicating possible alterations in muscarinic receptor characteristics. An increased sensitivity to muscarinic stimulation in day-wetting children was also suggested, whereas NKA is unlikely to be involved in any of these pathophysiological conditions.