Integration of mental health screening and treatment into cystic fibrosis clinics: Evaluation of initial implementation in 84 programs across the United States

BACKGROUND

A large-scale epidemiological study of 6088 individuals with cystic fibrosis (CF) and 4102 caregivers in nine countries documented elevated symptoms of depression and anxiety, leading to international guidelines for annual screening and follow-up. To facilitate national implementation, 84 CF programs funded a mental health coordinators (MHC). Implementation was evaluated after 1 year using the consolidated framework for implementation research (CFIR) to identify facilitators and barriers.

METHODS

A 45-item internet survey was developed to assess relevant CFIR implementation steps. Surveys were completed in 2016. It assessed five domains tailored to study aims: (a) Intervention characteristics, (b) outer setting, (c) inner setting, (d) characteristics of individuals, and (e) process of implementation.

RESULTS

Response rate was 88%, with pediatric and adult programs equally represented. A majority of MHCs were social workers (54.1%) and psychologists (41.9%); 41% had joined the team in the past year. Facilitators across the five domains included universal uptake of screening tools, greater awareness and detection of psychological symptoms, reduced stigma, and positive feedback from patients and families. Barriers included limited staff time, space, and logistics.

DISCUSSION

This is the largest systematic effort to integrate mental health screening and treatment into the care of individuals with a serious, chronic illness and their caregivers. MHCs implementing screening, interpretation and follow-up reported positive results, and significant barriers. This national implementation effort demonstrated that depression and anxiety can be efficiently evaluated and treated in a complex, chronic disease. Future efforts include recommending the addition of screening scores to national CF Registries and examining their effects on health outcomes.

The Current and Future Challenges of Hip Fracture Management in Malaysia

By 2050, it is predicted that six million hip fractures will occur each year of which the majority will happen in Asia. Malaysia is not spared from this predicted rise and its rate of increase will be one of the highest in this region. Much of this is driven by our unprecedented growth in the number of older people. Characteristics of individuals with hip fractures in Malaysia mirror what has been reported in other countries. They will be older multimorbid people who were already at risk of falls and fractures. Outcomes were poor with at least a quarter do not survive beyond 12 months and in those that do survive have limitation in their mobility and activities of daily living. Reviewing how these fractures are managed and incorporating new models of care, such as orthogeriatric care, could address these poor outcomes. Experts have warned of the devastating impact of hip fracture in Malaysia and that prompt action is urgently required. Despite that, there remains no national agenda to highlight the need to improve musculoskeletal health in the country.

The Trach Safe Initiative: A Quality Improvement Initiative to Reduce Mortality among Pediatric Tracheostomy Patients

OBJECTIVE

To describe the Trach Safe Initiative and assess its impact on unanticipated tracheostomy-related mortality in outpatient tracheostomy-dependent children (TDC).

METHODS

An interdisciplinary team including parents and providers designed the initiative with quality improvement methods. Three practice changes were prioritized: (1) surveillance airway endoscopy prior to hospital discharge from tracheostomy placement, (2) education for community-based nurses on TDC-focused emergency airway management, and (3) routine assessment of airway events for TDC in clinic. The primary outcome was annual unanticipated mortality after hospital discharge from tracheostomy placement before and after the initiative.

RESULTS

In the 5 years before and after the initiative, 131 children and 155 children underwent tracheostomy placement, respectively. At the end of the study period, the institution sustained Trach Safe practices: (1) surveillance bronchoscopies increased from 104 to 429 bronchoscopies, (2) the course trained 209 community-based nurses, and (3) the survey was used in 488 home ventilator clinic visits to identify near-miss airway events. Prior to the initiative, 9 deaths were unanticipated. After Trach Safe implementation, 1 death was unanticipated. Control chart analysis demonstrates significant special-cause variation in reduced unanticipated mortality.

DISCUSSION

We describe a system shift in reduced unanticipated mortality for TDC through 3 major practice changes of the Trach Safe Initiative.

IMPLICATION FOR PRACTICE

Death in a child with a tracheostomy tube at home may represent modifiable tracheostomy-related airway events. Using Trach Safe practices, we address multiple facets to improve safety of TDC out of the hospital.

88 The Truth Behind the Pubic Rami Fracture: Identification of Pelvic Fragility Fractures at A University Teaching Hospital

Introduction

Older patients presenting with pelvic fragility fractures (PFF) is an increasing epidemic. The most common pelvic fracture identified by plain radiograph is pubic rami fracture. These fractures are painful and often require admission to hospital. However, despite optimal analgesia, many of these patients struggle to mobilise and may have fractures of the posterior pelvic ring, which are overlooked and not visible on plain radiograph imaging. We aimed to quantify the number of patients progressing to further pelvic imaging in the form of computed tomography (CT) or magnetic resonance imaging (MRI) and the presence of concurrent fractures.

Methods

Prospective screening of pelvic imaging in patients aged over 70 years was undertaken at Nottingham University Hospitals NHS Trust over an 8-month period from October 2018.

Results

103 predominantly female (83%) patients were confirmed to have an acute fragility fracture of the pubic rami on plain radiograph. 19% of patients were discharged direct from the Emergency Department, 45% were admitted to Health Care of Older People (HCOP) teams, 30% to Trauma and Orthopaedic (T&O) teams and 6% to other specialities. 25% of the patients admitted underwent further pelvic imaging, which confirmed fragility fractures of the pubic rami in 88%, with 40% showing acetabular fractures and 68% showing sacral fractures of all types. A further 10 patients were diagnosed with pubic rami insufficiency fractures on further imaging, having had a normal initial radiograph, but had been admitted with poor mobility due to groin pain. In these 10 patients, 20% also had an acetabular fracture and 60% sacral fractures. Overall, 59% of patients with pubic rami fractures had an ipsilateral sacral fracture; a Type 1 Lateral Compression pelvic fracture by AO classification.

Conclusions

Pubic rami fractures are a significant problem in older people and often require admission to hospital. Further imaging confirms these fractures are complex, with co-existing fractures of the acetabulum and sacrum common. However despite this, only a quarter of patients admitted had further imaging. Where pelvic fractures are missed or severity not appreciated, appropriate pain control can be more difficult to achieve. With the potential for minimally invasive surgical options to aid pain management in sacral fractures, it may be prudent for all patients hospitalised with suspected or confirmed pelvic fracture to undergo further imaging.

89 Poor Attendance for DXA in Older People with A Low Trauma Fragility Fracture: A 6 Year Data Analysis of the Nottingham Fracture Liaison Service

Introduction

Hip Fractures are common and result in significant patient morbidity and increased mortality. Up to 40% of these patients have sustained a previous low-trauma fracture. The Department of Health advises that patients presenting with fragility fracture should have access to ‘Fracture Liaison Services (FLS)’. These are models of care which systematically identify patients at risk, assess bone health, treat patients (if needed) and follow patients up to support medication adherence.

Methods

Demographics of FLS patients between January 2012 and December 2017 was obtained retrospectively from the Nottingham University Hospitals FLS database. We examined DNA rates and further characteristics of these types of patients. Deprivation scores were deprived using the English indices of deprivation 2015 (1–Most deprived; 5-Least deprived). The 2016 cohort of patients were followed-up till January 2019 to assess for re-fractures.

Results

6528 high-risk patients were identified and referred to DXA. Mean (SD) age was 68±10.5 years [Females=5302 (81%)]. 1386 patients (21%) did not attend. High prevalence of non-attendance was in females [1032 patients (74%)] and the most deprived individuals [398 patients (29%)]. Females from the most deprived areas had the highest DNA rate [287 patients (29%)]. All eligible patients >75 years old were referred (n=1542 (100%), [Females=1284 (83%), non-attendance=473 (31%), non-attendance in females=390 (82%), highly deprived females=96 (25%)]. 826 patients were referred in 2016. Median follow-up time was 2.46 years (IQR 0.16–3.00 years). 52 patients (7%) re-fractured. 17 patients (33%) DNA their previous DXA scan [Females=12 patients (71%)].

Conclusions

Nottingham FLS have identified patients with fragility fractures that are high-risk for further fractures. Despite a dedicated FLS there is a DNA of 21%. Many patients that DNA are generally considered as having a high-risk of further fractures; females, older age and more deprived. Further studies are needed to explore why patients do not attend for bone density scanning.

The Nottingham Spinal Health (NoSH) Study: a cohort study of patients hospitalised with vertebral fragility fractures

Patients hospitalised with vertebral fragility fractures were elderly, multimorbid and frail and lead to poor outcomes. Their hospital treatment needs to consider this alongside their acute fracture. A systematic organised model of care, such as an adaptation of orthogeriatric hip fracture care, will offer a more holistic approach potentially improving their outcomes.

PURPOSE

Patients admitted to hospital with vertebral fragility fractures are elderly and have complex care needs who may benefit from specialist multidisciplinary input. To date, their characteristics and outcomes have not been reported sufficiently. This study aims to justify such a service.

METHODS

Patients admitted with an acute vertebral fragility fracture over 12 months were prospectively recruited from a university hospital in England. Data were collected soon after their admission, at discharge from hospital and 6 months after their hospital discharge on their characteristics, pain, physical functioning, and clinical outcomes.

RESULTS

Data from 90 participants were analysed. They were mainly elderly (mean age 79.7 years), multimorbid (69% had ≥ 3 comorbid condition), frail (56% had a Clinical Frailty Scale score ≥ 5), cognitively impaired (54% had a MoCA score of < 23) and at high risk of falls (65% had fallen ≥ 2 in the previous year). Eighteen percent died at 6 months. At 6 months post-hospital discharge, 12% required a new care home admission, 37% still reported their pain to be severe and physical functioning was worse compared with their preadmission state.

CONCLUSION

Patients hospitalised with vertebral fragility fractures were elderly, multimorbid, frail and are susceptible to persistent pain and disability. Their treatment in hospital needs to consider this alongside their acute fracture. A systematic organised model of care, such as an adaptation of orthogeriatric hip fracture care, will offer a more holistic approach potentially improving their outcomes.

Surveillance endoscopy after tracheostomy placement in children: Findings and interventions

OBJECTIVES/HYPOTHESIS

The Seattle Children's Hospital implemented the Trach Safe Initiative to improve airway safety in tracheostomy-dependent children (TDC). A key tenet of this initiative is surveillance endoscopy. The objectives of this study were to describe the prevalence of abnormal airway changes in TDC, identify risk factors for these changes, and describe the frequency of airway interventions.

STUDY DESIGN

Retrospective case series.

METHODS

This is a review of children 0 to 21 years old who underwent tracheostomy and surveillance endoscopy from February 1, 2014 to January 1, 2019. Descriptive statistics were used to report the prevalence of abnormal airway changes and interventions following tracheostomy. Pearson χ² tests and logistic regression were used to identify risk factors for the development of abnormal changes.

RESULTS

There were 127 children identified. The median time from tracheostomy to initial surveillance endoscopy was 1.6 months (interquartile range = 1.3-2.4 months). At initial endoscopy, 86.6% of patients had at least one abnormal airway finding. The most common findings were subglottic edema/stenosis (57.3%), glottic edema (37.3%), and suprastomal granulation tissue (31.8%). Prematurity and a history of failed extubations were significantly associated with abnormal findings on endoscopy (odds ratio [OR] = 7.2, P = .01 and OR = 4.1, P = .03, respectively). Of those with abnormal findings, 32.7% underwent an intervention to improve airway patency and safety. The most common interventions performed were suprastomal granuloma excision (44.4%), steroid injection (22.2%), and balloon dilation of the glottis or subglottis (19.4%).

CONCLUSIONS

The prevalence of early abnormal airway changes in TDC is high, particularly in young children with a history of prematurity and failed extubation.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:1327-1332, 2020.

Highlights from the 2018 North American cystic fibrosis conference

The 32nd annual North American Cystic Fibrosis Conference was held in Denver, CO on Oct. 18 to 20, 2018. This review highlights presentations in several topic areas, including the pathophysiology and basic science of cystic fibrosis lung disease, clinical trials, clinical care, and quality improvement. Citations from the conference are by first author and abstract or symposium number, as designated in the previously published supplement.

Highlights from the 2017 North American Cystic Fibrosis Conference

The 31st annual North American Cystic Fibrosis Conference (NACFC) was held in Indianapolis, IN on November 2-4, 2017. Abstracts of presentations from the conference were published in a supplement to Pediatric Pulmonology [2017; Pediatr Pulmonol Suppl. 52: S1-S776]. The current review summarizes several major topic areas addressed at the conference: the pathophysiology and basic science of cystic fibrosis (CF) lung disease, clinical trials, clinical management issues, and quality improvement (QI). In this review, we describe emerging concepts in several areas of CF research and care.

Highlights from the 2016 North American Cystic Fibrosis Conference

The 30th annual North American Cystic Fibrosis Conference (NACFC) was held in Orlando, FL, on October 27-29, 2016. Abstracts were published in a supplement to Pediatric Pulmonology. This review summarizes several major topic areas addressed at the conference: the pathophysiology of cystic fibrosis (CF) lung disease, clinical trials, clinical management issues, and quality improvement. We sought to provide an overview of emerging concepts in several areas of CF research and care, rather than a comprehensive review of the conference. Citations from the conference are by first author and abstract number or symposium number, as designated in the supplement.

Characterization of Inpatient Cystic Fibrosis Pulmonary Exacerbations

BACKGROUND AND OBJECTIVES

Pulmonary exacerbations lead to significant morbidity and mortality in patients with cystic fibrosis (CF). National consensus guidelines exist, but few studies report current practice in the treatment and monitoring of pulmonary exacerbations. The goal of this study was to characterize consistency and variability in the inpatient management of CF-related pulmonary exacerbations. We focused on the use of guideline-recommended maintenance therapies, antibiotic selection and treatment regimens, use of systemic corticosteroids, and frequency of lung function testing. We hypothesized that significant variability in these treatment practices exists nationally.

METHODS

This trial was a retrospective cross-sectional study. It included patients with CF aged ≤18 years hospitalized for pulmonary exacerbations between July 1, 2010, and June 30, 2015, at hospitals within the US Pediatric Health Information System database that are also Cystic Fibrosis Foundation-accredited care centers. One exacerbation per patient was randomly selected over the 5-year study period.

RESULTS

From 38 hospitals, 4827 individual pulmonary exacerbations were examined. Median length of stay was 10.0 days (interquartile range, 6-14.0 days). Significant variation was seen among centers in the use of hypertonic saline (11%-100%), azithromycin (5%-83%), and systemic corticosteroids (3%-61%) and in the frequency of lung function testing. Four different admission antibiotic regimens were used >10% of the time, and the most commonly used admission antibiotic regimen comprised 2 intravenous antibiotics with no additional oral or inhaled antibiotics (29%).

CONCLUSIONS

Significant variation exists in the treatment and monitoring of pulmonary exacerbations across Pediatric Health Information System-participating, Cystic Fibrosis Foundation-accredited care centers. Results from this study can inform future research working toward standardized inpatient pulmonary exacerbation management to improve CF care for children and adolescents.

Socioeconomic Status, Smoke Exposure, and Health Outcomes in Young Children With Cystic Fibrosis

BACKGROUND

Lower socioeconomic status (SES) and environmental tobacco smoke (ETS) exposure are both associated with poorer disease outcomes in cystic fibrosis (CF), and children with low SES are disproportionately exposed to ETS. We analyzed a large cohort of young children with CF to distinguish the impact of SES and ETS on clinical outcomes.

METHODS

The Early Pseudomonas Infection Control Observational study enrolled Pseudomonas-negative young children with CF <13 years of age. An enrollment survey assessed SES and ETS exposures. Forced expiratory volume in 1 second (FEV₁), crackles and wheezes, and weight-for-age percentile were assessed at each clinical encounter over at least 4 years. Repeated measures analyses estimated the association of SES and ETS exposures with longitudinal clinical outcomes, adjusting for confounders.

RESULTS

Of 1797 participants, 1375 were eligible for analysis. Maternal education was high school or less in 28.1%, 26.8% had household income <$40 000, and 43.8% had Medicaid or no insurance. Maternal smoking after birth was present in 24.8%, more prevalent in household with low SES. In separate models, lower SES and ETS exposure were significantly associated with lower FEV₁% predicted, presence of crackles or wheezes, and lower weight percentile. In combined models, effect estimates for SES changed minimally after adjustment for ETS exposures, whereas estimates for ETS exposures were attenuated after adjusting for SES.

CONCLUSIONS

ETS exposure was disproportionately high in low SES families in this cohort of children with CF. Lower SES and ETS exposure had independent adverse effects on pulmonary and nutritional outcomes. Estimated effect of SES on FEV₁ decreased minimally after ETS adjustment, suggesting health disparity risks independent of ETS exposure.