Avoidable Delays Research Articles

SS10. Financial Impact of Implementing Care Delivery Redesign Initiatives for Vascular Surgery in a Hospital Setting

A fragmented health care system contributes to suboptimal resource utilization and care coordination. A Care Delivery Redesign (CDR) for the vascular surgery service was developed to improve diagnosis-related group (DRG) assignment, to decrease length of stay (LOS), and to minimize care variation through standardized care pathways. We measured the value of CDR through hospital financial metrics. The CDR consisted of a physician champion, inpatient nurse practitioner, and dedicated case manager. The vascular surgery nurse practitioner played a central role in CDR by facilitating all aspects of patient care coordination, resident education, and communication with hospital coding specialists. A real-time weekly inpatient tracker was created and reviewed weekly during vascular conference. The tracker contains patient identifier, admission and discharge date, attending, admission and discharge unit, current LOS, Centers for Medicare and Medicaid Services geometric mean LOS, and corresponding DRG. Tools created to track performance and to ensure sustainability included daily discussions of barriers and solutions on patient rounds, creation of a vascular surgery mobile app for residents, and a patient avoidable delay tracker. End points included LOS, total variable cost, case mix index, and vascular surgery contribution margin compared with pre-CDR contribution margin. Implementation of CDR resulted in a 23% decrease in LOS, reducing the gap to Centers for Medicare and Medicaid Services geometric mean LOS by 1.6 days, from 2.2 days to 0.5 day. Improvement and changes in documentation captured accurate DRGs, which resulted in an increase in case mix index of 21%. This resulted in contribution margin amounting to $1.88 million. The CDR structure as described reduces hospital LOS and improves financial service metrics. The structure is predicated on a dedicated service line advanced practitioner, weekly service tracker review, and real-time management of barriers and solutions to system-related issues. As designed, CDR provided significant financial benefit to the hospital while facilitating patient care.

Reducing the Time from Surgery to Adjuvant Radiation Therapy: An Institutional Quality Improvement Project.

Objective The National Comprehensive Cancer Network guidelines recommend an interval between surgery and adjuvant radiation therapy of less than 6 weeks, but only 44% of patients meet this metric nationally. We sought to identify key components of an improvement process focused on starting adjuvant radiation therapy within 6 weeks of surgery. Methods This project used an A3 model to improve a defined process measure. We studied a consecutive sample of 56 patients with oral cavity carcinoma who were treated at our institution with upfront surgical resection followed by adjuvant radiation therapy. Twelve proposed interventions tested during the study period focused on 3 key drivers of delays: delayed dental evaluation and teeth extraction, delayed radiation oncology consults, and inadequate patient engagement. The primary outcome measure was the number of days from surgery to the start of radiation therapy. Results Prior to the intervention, 62% of patients received adjuvant radiation within 6 weeks of surgery. Following the intervention, 73% of patients achieved this metric. The percentage of patients with avoidable delays decreased from 24% to 9%. The percentage of patients with unavoidable delays was relatively constant before and after the intervention (15% and 18%, respectively). Discussion Defining disease-specific metrics is critical to improving care in our head and neck cancer patient population. We demonstrate several key components to develop and improve self-defined metrics. Implications for Practice As we transition to a system of value-based care, structured quality improvement projects can have a measurable impact on cancer patient process measures.

Australian general practitioner attitudes to residential aged care facility visiting.

Demographic trends suggest that the sustainability of the general practitioner (GP) Residential Aged Care Facility (RACF) workforce, worldwide and in Australia, is under threat, compromising the ongoing care of chronically ill RACF residents. It is therefore important to ascertain current GP attitudes towards this work, to better understand and hypothesise means of reversing this trend. To this end, during 2014 the views of 26 GPs and GP Registrars working in rural and regional New South Wales, Australia, were captured during focus group discussions and one-on-one interviews. Analysis of the qualitative date revealed that GP attitudes towards RACF visiting fell into five key themes: pleasure, duty, remuneration and logistics, hesitation, and frustration. The data also revealed that the overriding emotion GPs felt about RACF visitation was frustration with the avoidable delays and inefficiencies associated with the work. Despite the pleasure GPs derived from their work in RACFs and their sense of obligation to be involved, their hesitation and frustration was compounded by the work's perceived poor remuneration. This research suggests that the barriers to GP participation in RACF visiting were managerial rather than attitudinal, and that a strategic focus upon improving administrative and logistical support is needed.

Optimizing Efficiency in the Evaluation of Living Donor Candidates: Best Practices and Implications

An inefficient living donor candidate evaluation process can be a barrier to timely living donor transplantation and optimal donor satisfaction. In this review, we examine the inefficiencies of the living kidney donor evaluation and make recommendations to optimize this process. There is increasing awareness that the living donor evaluation process is inefficient, but little research has been done to date. The time to complete the evaluation can be several or even many months. Avoidable delays can lead to dialysis initiation for pre-emptive transplant candidates, lengthen dialysis time for those patients on dialysis, and reduce donor satisfaction. Opportunities to improve efficiency include the choice, timing, sequencing of evaluation tests, procedures and consults, use of navigators, and monitoring of evaluation timeliness as a quality metric. A more efficient evaluation is expected to result in better health outcomes for patients with kidney failure and incur substantial cost savings to the healthcare system.

Symptoms in primary care with time to diagnosis of brain tumours.

BackgroundBrain tumours often present with varied, non-specific features with other diagnoses usually being more likely.ObjectiveTo examine how different symptoms and patient demographics predict variations in time to brain tumour diagnosis.MethodsWe conducted a secondary analysis of brain tumour cases from National Audit of Cancer Diagnosis in Primary Care. We grouped neurological symptoms into six domains (headache, behavioural/cognitive change, focal neurology, ‘fits, faints or falls’, non-specific neurological, and other/non-specific) and calculated times for patient presentation, GP referral, specialist consultation and total pathway interval. We calculated odds ratios (ORs) for symptom domains comparing the slowest to other quartiles.ResultsData were available for 226 cases. Median (interquartile range) time for the total pathway interval was 24 days (7–65 days). The most common presentation was focal neurology (33.2%) followed by ‘fits, faints or falls’ and headache (both 20.8%). Headache only (OR = 4.11, 95% CI = 1.10, 15.5) and memory complaints (OR = 4.82, 95% CI = 1.15, 20.1) were associated with slower total pathway compared to ‘fits, faints or falls’. GPs were more likely to consider that there had been avoidable delays in referring patients with headache only (OR = 4.17, 95% CI = 1.14, 15.3).ConclusionPatients presenting to primary care with headache only or with memory complaints remain problematic with potentially avoidable delays in referral leading to a longer patient pathway. This may or may not impact on the efficacy and morbidity of therapies. Additional aids are required to help doctors differentiate when to refer headaches and memory complaints urgently for a specialist opinion.

Determinants of Decision to Delivery Interval (DDI) in Emergency Caesarean Sections in Ladoke Akintola University of Technology Teaching Hospital Ogbomoso, Nigeria

Background: Emergency caesarean sections are invaluable when vaginal delivery is either impossible or possess risk to the life of mother and or the foetus. Patients however still encounter delays after the decision has been made, despite recommended time frame. Objective: This is to identify the common indications for emergency caesarean section, factors responsible for delays after decision has been made and the short-term effect on the mother and neonate. Materials and methods: This was a retrospective study in which case records of patients who had emergency caesarean section were retrieved. Information about sociodemographic characteristics, booking status, parity, indication for surgery, decision time, incision time and short term feto-maternal outcomes were collected with the aid of structured proforma. Data was analyzed with Stata: Release 13 statistical software. Results: The mean age of participants was 28.9 ± 5.1 years, 51.3% were booked, primary caesarean section rate was 84.0%. The commonest indication was cephalo-pelvic disproportion (40.5%). The mean DDI was 145.3 ± 69.2 min. Patients’ factor was the leading cause of delay due to lack of funds and non-provision of surgical materials (53.5%). Leading hospital factors were non-availability of blood and blood products (32.8%) and power outage (28.0%). Five min APGAR score was normal in 92.3% of the neonates and 0.5% had severe asphyxia. Conclusion: This study shows that there are still avoidable delays in emergency caesarean section. Although there were no immediate neonatal complications, improving health care delivery so as to eliminate the identified causes would go a long way in reducing these delays.

Morts maternelles par accident vasculaire cérébral. Résultats de l'ENCMM, FRANCE 2010-2012

Stroke is a rare event during pregnancy (10/100,000) and can be ischemic (24%), hemorrhagic (74%) or both (2%). Pregnancy probably increases the risk even if it is discussed for arteriovenous malformation (AVM), aneurismal subarachnoid hemorrhage (SAH) and cavernomas. Between 2010 and 2012, 31 maternal deaths were associated with stroke. In 22 cases, stroke was the direct cause of death giving a maternal mortality ratio of 0,9/100,000 witch is not different from the former report (2007–2009). There were 2 cerebral thrombophlebitis, 2 ischemic strokes and 18 hemorrhagic strokes (4 SAH, 2 AVM). These deaths occurred during ongoing pregnancy in 5 cases (25%), after miscarriage in 1 case (5%) and in the post-partum period in 14 cases (70%). In this last situation, stroke occurred before delivery in 4 cases and during the post-partum period in 9 cases (1 to 9 days) (1 unknown). There were 7 vaginal deliveries (50%) and 6 emergency cesarean sections (43%) (1 unknown). Most of those deaths were considered to be unavoidable (13/17, 76%). Four deaths were considered by the experts as being possibly avoidable (delay diagnosis, diagnostic error, inadequate treatment, lake of interruption of the pregnancy). Analyzing those deaths remind that any sudden, severe and unusual headache must be explored and that pregnancy does not contraindicate any of the diagnostic examinations (TDM, angio-TDM, MRI) or invasive treatments (surgery, arterio-embolization, fibrinolysis) necessary for its management. Furthermore, the diagnosis of postdural puncture headache should not be establishedwithout imaging when the symptomatology is not absolutely typical.

Delays in the diagnosis and treatment of bone and joint tuberculosis in the United Kingdom.

Tuberculosis (TB) infection of bones and joints accounts for 6.7% of TB cases in England, and is associated with significant morbidity and disability. Public Health England reports that patients with TB experience delays in diagnosis and treatment. Our aims were to determine the demographics, presentation and investigation of patients with a TB infection of bones and joints, to help doctors assessing potential cases and to identify avoidable delays. This was a retrospective observational study of all adults with positive TB cultures on specimens taken at a tertiary orthopaedic centre between June 2012 and May 2014. A laboratory information system search identified the patients. The demographics, clinical presentation, radiology, histopathology and key clinical dates were obtained from medical records. A total of 31 adult patients were identified. Their median age was 37 years (interquartile range (IQR): 29 to 53); 21 (68%) were male; 89% were migrants. The main sites affected were joints (10, 32%), the spine (8, 26%) and long bones (6, 19%); 8 (26%) had multifocal disease. The most common presenting symptoms were pain (29/31, 94%) and swelling (26/28, 93%). 'Typical' symptoms of TB, such as fever, sweats and weight loss, were uncommon. Patients waited a median of seven months (IQR 3 to 13.5) between the onset of symptoms and referral to the tertiary centre and 2.3 months (IQR 1.6 to 3.4.)) between referral and starting treatment. Radiology suggested TB in 26 (84%), but in seven patients (23%) the initial biopsy specimens were not sent for mycobacterial culture, necessitating a second biopsy. Rapid Polymerase Chain Reaction-based testing for TB using Xpert MTB/RIF was performed in five patients; 4 (80%) tested positive for TB. These patients had a reduced time between the diagnostic biopsy and starting treatment than those whose samples were not tested (median eight days versus 36 days, p = 0.016). Patients with bone and joint TB experience delays in diagnosis and treatment, some of which are avoidable. Maintaining a high index of clinical suspicion and sending specimens for mycobacterial culture are crucial to avoid missing cases. Rapid diagnostic tests reduce delays and should be performed on patients with radiological features of TB. Cite this article: Bone Joint J 2018;100-B:119-24.

Adherence to a Nurse-Driven Feeding Protocol in a Pediatric Intensive Care Unit.

Patients admitted to pediatric intensive care units (PICUs) often experience prolonged periods without nutrition support, which may result in hospital-induced malnutrition and longer length of stay. Nurse-driven feeding protocols have been developed to prevent unnecessary interruptions or delays to nutrition support. The primary objective of this study was to identify compliance and reasons for noncompliance to a feeding protocol at a tertiary care hospital PICU in Canada. The secondary aim was to determine the mean time (hours) spent without any form of nutrition and to identify reasons for time spent without nutrition. This was a prospective cohort audit, consisting of 150 consecutive PICU admissions (January-February 2016). Exclusion criteria consisted of patient mortality within 48 hours (n = 1) and patients who were still admitted at the end of the data collection timeframe (n = 7). The remaining cohort consisted of 142 consecutive admissions. Data collection took place in real time and included patient demographics, diagnostic categories, time spent without nutrition, reasons for interruptions to nutrition support, and reasons for noncompliance to the protocol. Observations were obtained through paper and computer charts and conversing with clinicians. There was a 95% compliance rate to the protocol and an average of 25.6 hours spent without nutrition per patient. The most prevalent reason for noncompliance was an avoidable delay to restart feeds before/after procedures or after surgery. A nurse-driven feeding protocol may reduce time spent without nutrition. Future research is required to examine the relationship between adherence to feeding protocols and clinical outcomes.

ANALYSIS OF TIME CONSUMPTION DURING SESSILE OAK FELLING AND PROCESSING WORKS APPLYING THE FULL-LENGTH METHOD

UDK: 630*32:658.53(497.6 Olovo) This paper presents an analysis of full-length method used in the phase of sessile oak felling and sorting works. The aim of the research was to establish time consumption during sessile oak felling and sorting works using full-length processing method. The research was conducted in the area managed by Forest enterprise "Šumsko – privredno društvo Zeničko-dobojskog kantona" Zavidovići, Management unit "Šumarija" Olovo, Forest unit "Krivaja", compartment 112. The sampling method was applied for measuring time consumption of work operations. It was established that the share of effective time in total time was 67.12%, the share of unavoidable delay times was 30.79%, and the share of avoidable delay times was 2.09%. Time consumption of tree felling and processing was strongly affected from tree diameter at the breast height (R2=0.656). The achieved results will be used for further research on this topic, which has been unduly neglected in the past few years in the BH forestry. Further research would certainly include ergonomics, economy of work procedures, occupational safety and environmental consequences of forestry work.

Morts maternelles par accident vasculaire cérébral. Résultats de l'ENCMM, FRANCE 2010-2012

Stroke is a rare event during pregnancy (10/100,000) and can be ischemic (24%), hemorrhagic (74%) or both (2%). Pregnancy probably increases the risk even if it is discussed for arteriovenous malformation (AVM), aneurismal subarachnoid hemorrhage (SAH) and cavernomas. Between 2010 and 2012, 31 maternal deaths were associated with stroke. In 22 cases, stroke was the direct cause of death giving a maternal mortality ratio of 0,9/100,000 witch is not different from the former report (2007–2009). There were 2 cerebral thrombophlebitis, 2 ischemic strokes and 18 hemorrhagic strokes (4 SAH, 2 AVM). These deaths occurred during ongoing pregnancy in 5 cases (25%), after miscarriage in 1 case (5%) and in the post-partum period in 14 cases (70%). In this last situation, stroke occurred before delivery in 4 cases and during the post-partum period in 9 cases (1 to 9 days) (1 unknown). There were 7 vaginal deliveries (50%) and 6 emergency cesarean sections (43%) (1 unknown). Most of those deaths were considered to be unavoidable (13/17, 76%). Four deaths were considered by the experts as being possibly avoidable (delay diagnosis, diagnostic error, inadequate treatment, lake of interruption of the pregnancy). Analyzing those deaths remind that any sudden, severe and unusual headache must be explored and that pregnancy does not contraindicate any of the diagnostic examinations (TDM, angio-TDM, MRI) or invasive treatments (surgery, arterio-embolization, fibrinolysis) necessary for its management. Furthermore, the diagnosis of postdural puncture headache should not be establishedwithout imaging when the symptomatology is not absolutely typical.

Identifying barriers to admission avoidance in an emergency care pathway

Home ward Ealing was launched in October 2015 by West London Mental Health NHS Trust and partners in order to support the aspiration of health and social care commissioners to maximise opportunities to avoid unnecessary non-elective admissions. Home ward provides sub-acute care for Ealing patients in their own homes or in Magnolia Ward in Clayponds (community) Hospital. After nine months of operation, the overall number of referrals into the service has increased significantly compared with the predecessor service, however numbers of non-elective admissions continued to rise. Communication between the Home ward partnership and the emergency department indicated anecdotal concerns about delays in referrals for patients for whom an admission may have been avoided. A survey was undertaken of forty-four consecutive referrals between 20-30 June 2016 to Home ward from the emergency department to examine whether Home ward intervention was occurring early enough in the acute patient pathway to avoid admission, and to identify other avoidable delays contributing to inefficient care and poor patient experience. Results showed that only a small minority of cases were seen and discharged in under 4 hours, even though two thirds were identified and assessment initiated rapidly in pre-admission areas. 91% of attendances converted to trigger a short stay admission tariff due to patients being transferred to the Clinical Decisions Unit (CDU). Nearly half of patients were admitted to an observation ward before a decision was made to admit or discharge, suggesting potential benefit for including such a facility as part of the admission avoidance pathway. For the intermediate care population: if you reach the hospital, you'll find yourself in a bed. We concluded that opportunities in the ED to avoid conversion to a short-stay admission are limited, with most patients identified as potentially suitable for intermediate care being transferred to CDU before discharge decision was made. Greater emphasis on attendance avoidance (through GP and Ambulance Service liaison) may be more effective at avoiding admissions than work at the front door of the hospital.

Weaknesses and capacities affecting the Prehospital emergency care for victims of road traffic incidents in the greater Kampala metropolitan area: a cross-sectional study

BackgroundPre-hospital emergency care is a vital and integral component of health systems particularly in the resource constrained countries like Uganda. It can help to minimize deaths, injuries, morbidities, disabilities and trauma caused by the road traffic incidents (RTIs). This study identifies the weaknesses and capacities affecting the pre-hospital emergency care for the victims of RTIs in the Greater Kampala Metropolitan Area (GKMA).MethodsA cross-sectional study was conducted in the GKMA using a three-part structured questionnaire. Data related to the demographics, nature of RTIs and victims’ pre-hospital experience and existing Emergency Medical Services (EMS) were collected from victims and EMS specialists in 3 hospitals and 5 EMS institutions respectively. Data was descriptively analyzed, and after the principal component analysis was employed to identify the most influential weaknesses and capacities affecting the pre-hospital emergency care for the victims of RTI in the GKMA.ResultsFrom 459 RTI victims (74.7% males and 25.3% females) and 23 EMS specialists (91.3% males and 8.7% females) who participated in the study between May and June 2016, 4 and 5 key weaknesses and capacities respectively were identified to affect the pre-hospital emergency care for RTI victims in the GKMA. Although some strengths exist like ambulance facilitation, EMS structuring, coordination and others), the key weaknesses affecting the pre-hospital care for victims were noted to relate to absence of predefined EMS systems particularly in the GKMA and Uganda as a whole. They were identified to involve poor quality first aid treatment; insufficient skills/training of the first responders; inadequate EMS resources; and avoidable delays to respond and transport RTI victims to medical facilities.ConclusionsThough some strengths exist, the weaknesses affecting prehospital care for RTI victims primarily emanate from the absence of predefined and well-organized EMS systems in the GKMA and Uganda as a whole.

Evaluation of pediatric cochlear implant care throughout Europe: Is European pediatric cochlear implant care performed according to guidelines?

Objectives: International guidelines indicate that children with profound hearing loss should receive a cochlear implant (CI) soon after diagnosis in order to optimize speech and language rehabilitation. Although prompt rehabilitation is encouraged by current guidelines, delays in cochlear implantation are still present. This study investigated whether European countries establish timely pediatric CI care based on epidemiological, commercial, and clinical data.Methods: An estimation of the number of pediatric CI candidates in European countries was performed and compared to epidemiological (Euro-CIU), commercial (Cochlear®), and clinical (institutional) age-at-implantation data. The ages at implantation of pediatric patients in eight countries (the Netherlands, Belgium, Germany, the United Kingdom, France, Turkey, Portugal, and Italy) between 2005 and 2015 were evaluated.Results: From 2010 onwards, over 30% of the pediatric CI candidates were implanted before 24 months of age. Northern European institutions implanted children on average around 12 months of age, whereas southern European institutions implanted children after 18 months of age. The Netherlands and Germany implanted earliest (between 6 and 11 months).Discussion: Implemented newborn hearing screening programs and reimbursement rates of CIs vary greatly within Europe due to local, social, financial, and political differences. However, internationally accepted recommendations are applicable to this heterogeneous European CI practice. Although consensus on early pediatric cochlear implantation exists, this study identified marked delays in European care.Conclusion: Regardless of the great heterogeneity in European practice, reasons for latency should be identified on a national level and possibilities to prevent avoidable future implantation delays should be explored to provide national recommendations.

Gender and leprosy-related stigma in endemic areas: A systematic review

Background: The social impact of leprosy is said to exacerbate existing gender inequalities, but what is the evidence for this? What are the differences and similarities in leprosy-related stigma experiences between men and women? Methods: A systematic search was done in PubMed, Web of Science, PsycInfo and CINAHL databases, using the web-based version of Mendeley and following PRISMA guidelines. Search terms used in the search syntaxes involved synonyms for leprosy, stigma, and sex or gender. Criteria for eligibility were articles providing data on leprosy-related stigma separate for men and/or women, Dutch or English language, access to full-text copy, information based on primary data (excluding reviews), and a sample group of leprosy-affected subjects above 15 years old, living in leprosy-endemic areas. Case reports were excluded. Findings: 18 articles met the criteria and were reviewed. They demonstrated a female gender disadvantage, in the social, health and/or psychological domain. This was evidenced by a higher percentage of women experiencing stigma, a lower quality of life score for women, and a higher mental burden among women compared to controls. Only one article indicated higher perceived stigma in men compared to women, in society and in social institutions. Overall, it was found that womens inferior position results in more rejection at family and community level, more difficulties in their marital position, more social avoidance, more concealment and treatment delay, and more self-stigmatisation. All these factors and the lower female social status mutually reinforce each other. It is argued that this gender inequality is the case in other neglected tropical diseases and stigmatising conditions as well. Conclusion: The consensus that female leprosy patients are more severely affected by leprosy-related stigma than male patients is supported by 12 of the 18 reviewed articles, and by other literature. These findings highlight a need for gender sensitivity in leprosy interventions to reduce leprosy-related stigma and its impact, especially among women and girls.

Identifying factors impacting hospital length of stay and potentially avoidable discharge delays in patients with gynecologic cancer

Identifying factors impacting hospital length of stay and potentially avoidable discharge delays in patients with gynecologic cancer

Impact of linear correlation on construction project performance using stochastic linear scheduling

BackgroundIn the construction industry, the productivity of all trades is directly impacted by uncertainty and variability. For repetitive projects, smooth work flow of productive resources is necessary to minimize or eliminate interruptions and idle time with the objective of reducing costs. An ideal or near optimal solution requires careful planning of the sequence, timing and resource allocations for each activity. Earlier research has demonstrated that uncertainty in the duration of repeated activities can have a significant impact on what is determined to be the optimum project plan. This suggests that correlation in the duration of repeated activities (where durations are stochastic) may also be important in determining the most favorable plan.MethodsThis study assesses the significance of correlation in this respect, using a Linear Scheduling framework for modeling repetitive construction work. Numerical and graphical results are used in a case study to evaluate and compare the optimal solution derived for both deterministic and stochastic environments. For the stochastic environment, a range of levels of correlation are considered using linear correlation between immediate successor repetitions of an activity.ResultsThe results provide insight into the effects of different degrees of correlation on the expected project duration, cost, crew and equipment idle times and interruptions. The correlation level has effects that translate into performance tradeoffs depending on the initial plan assumptions applied to the activities.ConclusionsThe impact of full correlation on the optimality of a project plan was found, on average, to introduce idle time to crews equal to 7% of their active time, and to cause avoidable delays to the completion of a project equal to 12% of the project duration. The authors believe these inefficiencies justify further investigation of the impact of correlation on construction projects, including the development of more sophisticated models of correlation.

An evaluation of operating room throughput in a stand-alone soft-tissue trauma operating theatre.

Operating room time is a limited, expensive commodity in acute hospitals. Strategies aimed at reduction of non-operative time improve operating room throughput and capacity. We conducted a prospective study to evaluate and augment operating room throughput and capacity using context-specific work practice changes. Following institutional and ethical approval, an interdisciplinary group designed and introduced a series of work practice changes specific to a stand-alone soft tissue trauma theatre, comprising modifications to patient processing, staff behaviours and additional anaesthesiologist hours. Time intervals relating to each patient were measured during a 16 week period before and after implementing work practice changes. The primary outcome measure was non-operative time, with daily caseload and cancellations amongst secondary outcome measures. 251 procedures were included over 58 working days (8 to 17 Monday to Friday). Non-operative time [55.6 (31.1) vs 52.3 (9.8) minutes, p = 0.48], daily caseload [4 [1-9] vs 4 [2-7], p = 0.56], and the number of daily cancellations [3 [0-11] vs 5 [0-8], p = 0.38], did not differ between baseline and study phases. Regional anaesthesia for upper limb surgery increased during the study phase [26/59 (44.0%) vs 10/63 (15.9%), p = 0.014] with resultant decrease in mean duration of recovery room stay [20.7 (17.7) vs 30 (20.5) minutes, p = 0.0001] and increased recovery room bypass [26/116 (22.4%) vs 6/135 (4.4%), p = 0.0002]. Avoidable delays accounted for 124.8 (72.2) minutes of theatre time lost each day. In conclusion, additional attending anaesthesiologist hours combined with work practice changes did not impact on measures of theatre throughput and capacity. The study identified important variables that contribute to avoidable delays, and points the way for future research.

Australian children living with rare diseases: experiences of diagnosis and perceived consequences of diagnostic delays

BackgroundChildren and families living with rare disease often experience significant health, psychosocial, economic burdens and diagnostic delays. Experiences appear to be constant, regardless of the specific rare disease diagnosis. Systematically collected Australian data to support policy response on rare diseases are scarce. We address this gap by providing survey results about 462 children aged <19 years living with approximately 200 different rare diseases.ResultsOf 462 children, 96% were born in Australia, 55% were male, median age was 8.9 years (0–18.2). Four-hundred-and-twenty-eight (93%) had received a definitive diagnosis but 29 (7%) remained undiagnosed. Before receiving the correct diagnosis 38% consulted ≥ 6 different doctors. Among those with a diagnosis, 37% believed the diagnosis was delayed and 27% initially received a wrong diagnosis. Consequences of delayed diagnosis include anxiety, loss of reproductive confidence because of an ill-defined genetic risk, frustration and stress (54%), disease progression (37%), delays in treatment (25%) and inappropriate treatments (10%). Perceived reasons for diagnostic delays included lack of knowledge about the disease among health professionals (69.2%), lack of symptom awareness by the family (21.2%) and difficulties accessing tests (17.9%). Children with inborn errors of metabolism were less likely to have a delayed diagnosis compared with other disease groups (Chi-Sq = 17.1; P < 0.0001), most likely due to well-established and accessible biochemical screening processes. Diagnosis was given in person in 74% of cases, telephone in 18.5% and via a letter in 3.5%. Some families (16%) were dissatisfied with the way the diagnosis was delivered, citing lack of empathy and lack of information from health professionals. Psychological support at diagnosis was provided to 47.5%, but 86.2% believed that it should always be provided. Although 74.9% of parents believed that the diagnosis could have an impact on future family planning, only 44.8% received genetic counselling.ConclusionParents of children living with rare chronic and complex diseases have called for better education, resourcing of health professionals to prevent avoidable diagnostic delays, and to facilitate access to early interventions and treatments. Access to psychological support and genetic counselling should be available to all parents receiving a life-changing diagnosis for their child.

Esext3 for Reducing the Effect of Harboring Bug in File System

One of the most critical threats to the reliability and robustness for file system is harboring bug (silent data corruption). In this research we focus on checksum mismatch since it occurs not only in the user data but also in file system. Our proposed solution has the ability to check this bug in file system of Linux. In our proposed solution there is no need to invoke or revoke checker utility, it comes as the integrated part of file system and has the ability to check upcoming updates before harboring bug make unrecoverable changes that leads significant data loses. Demonstration testing shows satisfactory results in file server and web server environments in terms of less memory consumption and avoidable delay in system’s updating.