Decrease Wait Times Research Articles

Wait times for breast cancer surgery: effect of magnetic resonance imaging and preoperative investigations on the diagnostic pathway.

Women with breast cancer often require an extensive diagnostic work-up. We sought to determine the overall wait time, from the patient's perspective, from identification of an imaging abnormality to definitive treatment. The objective was to identify which factors contribute to overall wait time in women with breast cancer. A retrospective chart review in a tertiary care center was performed to identify all women who had breast surgery for invasive carcinoma and ductal carcinoma in situ. We recorded the dates of first imaging abnormality, first biopsy, subsequent imaging and biopsy, first consultation with any physician at the cancer center, first surgical consultation, and date of surgery. Clinical data that might influence these dates were then extracted. Wait times were calculated and factors associated with wait times were described. Eligible consecutive women with a cancer diagnosis (n = 264) were identified. The median time between first imaging abnormality and definitive surgery was 79 days. The median time from first surgical consultation to surgery was significantly longer in women who underwent magnetic resonance imaging and in women who underwent initial imaging outside of our tertiary care center (P < .05). On multivariable analysis, the modifiable factors associated with prolonged wait times included number of preoperative clinic visits, number of visits to radiology, and initial imaging outside of our center (P < .05). Extensive diagnostic work-up is an important factor that affects the time to definitive surgery. A more integrated approach using a rapid diagnostic clinic for tissue diagnosis initially, followed by facilitated preoperative evaluation, may potentially decrease wait times in breast evaluation.

Decreased wait times after institution of office-based hand surgery in a Veterans Administration setting.

Carpal tunnel syndrome is a common peripheral nerve compression disorder causing symptoms of numbness, tingling, weakness, and muscle atrophy. Open carpal tunnel release (CTR) is a common treatment modality traditionally performed in the operating room with sedation or general anesthesia. It can also be performed in the surgeon’s office under local anesthesia only. 1 In our study, we examined the number of days from initial consultation and visit to operative intervention in a Veterans Administration (VA) setting. A significant decrease in wait time from initial consultation to operative intervention and from initial visit to operative intervention was hypothesized to occur with the transition to office-based hand surgery procedures, without an increase in complications. Methods | Institutional review board approval from the Richard L. Roudebush VA Medical Center was obtained to construct a database of recent surgical procedures performed for carpal tunnel syndrome by the plastic surgery service. Operations including CTR in conjunction with other procedures were excluded. The minor procedure room is located within the plastic surgery clinic, with a single nurse serving as a circulating nurse. The hand and forearm are prepped and draped, and both monopolar cautery and bipolar cautery are available. A more specific description to a similar configuration can be found in

Nurse-administered intravitreal injections: a systematic review

Dear Editor: The growing elderly population and prevalence of diabetes mellitus have increased the number of patients with exudative age-related macular degeneration (AMD) and diabetic macular edema (DME) [1–4]. This has created a need to explore more cost-effective methods of delivering anti-vascular endothelial growth factor (VEGF) therapy [5]. One approach is to use nurses instead of physicians to administer the intravitreal injections of anti-VEGF agents. We have systemically reviewed the literature on the safety and efficacy of this treatment model. We searched articles in PubMed, Medscape and Google Scholar for the terms “retina and nurses,” “nurse injection” and “demand for ophthalmologists” from 2006 to 2014. Our inclusion criterion was nurse administration of intravitreal injections. For each paper, we recorded the number of nurses administering the injections, the training received by nurses, the number of injections, and the length of the study. We determined safety through reported vision-threatening complications. We evaluated efficacy through reported measures of patient satisfaction and efficiency. Our search produced 20 publications; four met the inclusion criteria. All four studies described safety audits of nurseadministered intravitreal injections in the United Kingdom (UK); the studies’ salient features are outlined in Table 1. The previous experience and training of the nurse injectors and the number of initial injections they performed under direct supervision by an ophthalmologist varied in each study. In all studies, the ophthalmologists retained responsibility for diagnostic and therapeutic decisions. The study with the highest sample number (10,006 injections) over the longest duration (5.5 years) reported a 0.04 % rate of post-injection endophthalmitis [8]; the other studies reported no major adverse events. The three smaller studies [6, 7, 9] reported positive patient satisfaction surveys; the studies also reported improved clinic efficiency using measures such as increased mean number of injections over fewer injection clinic days, and improved patient access to injections with decreased wait time and increased access to retina specialists. The literature on nurse-administered intravitreal injections has several limitations. The small number of published studies and the localization of research to the UK restricted the generalizability of study findings. Additionally, the variability in nurse training and in measuring clinic efficiency precluded definitive conclusions regarding the most appropriate training for nurse injectors or the efficacy of nurse-versus-physician-administered injections. These limitations notwithstanding, the use of nurses to administer intravitreal injections merits further study, especially in healthcare settings outside the UK. Presentation This work was submitted for presentation at the Association for Research in Vision and Ophthalmology (ARVO) Annual Meeting, 3–7 May 2015, in Denver, Colorado, USA. E. Li : P. B. Greenberg Division of Ophthalmology, The Warren Alpert Medical School of Brown University, Providence, RI, USA

Using real time locating systems (RTLS) to redesign room allocation in an ambulatory cancer care setting.

157 Background: Growing clinics need innovative ways to maximize capacity to ensure efficiency, a core element of quality care. Providers at the Dana-Farber Cancer Institute (DFCI) are assigned specific exam rooms for each clinic day. Despite room utilization below 50%, providers reported feeling constrained, and patients waited an average of 15 minutes to room. Furthermore, in February 2014, DFCI consolidated two facilities requiring that clinics absorb an immediate 10% increase in patient volume using available capacity. We sought to redesign the exam room allocation process by leveraging RTLS. Methods: Using computer simulation, we compared three options for allocating exam rooms. The simulation indicated a “pooled” room approach that did not designate rooms to individual providers would minimize patient wait time. A team was assembled to pilot the intervention in one clinic. An algorithm was developed to prioritize patients based on appointment time, arrival time, and provider availability. We utilized RTLS to automate the algorithm and indicate available exam rooms to coordinate transport of patients from the waiting area to exam rooms. Patient wait time was extracted from RTLS and compared between the baseline (provider-designated rooms) period and the post-intervention (pooled, undesignated rooms) period. Providers were asked post-intervention to provide feedback using a survey. Results: There was a significant decrease in the average wait to exam room despite a simultaneous increase in average appointment volume during the post-intervention period. Cumulative wait time gains averaged 3.3 hours daily. In addition, providers preferred the pooled rooming method over the designated rooming method. Conclusions: Allowing providers to utilize any available room has allowed this clinic to efficiently accommodate a larger number of appointments per day with an overall decrease in patient wait time. RTLS provided the real-time information necessary to succeed and drive improvement initiatives. [Table: see text]

SMART chemotherapy: A comprehensive cancer center’s journey to shared medical appointments.

135 Background: Shared medical appointments (SMA) offer a novel approach to improve efficiency and quality of care consistent with the goals of the Institute of Medicine. To our knowledge, there are no established SMA models for oncology patients undergoing treatment. Our objective was to develop and implement a SMA for chemotherapy education and clearance for women with gynecologic cancer. Methods: We first assessed the level of interest in SMAs among our patients and providers through qualitative interviews. We subsequently created a multidisciplinary team comprised of physicians, mid-level providers, nurses, pharmacists, administrators, health education specialists and members of the QI Department. Our project consisted of several phases: 1) provider buy-in, 2) program development, 3) staff education, 4) implementation; and 5) patient recruitment. A plan-do-study-act cycle was performed following each SMA, using patient and provider feedback. Appropriate modifications were made before the subsequent SMA. Results: Both patients and providers identified pre-chemotherapy as an optimal area to pilot SMAs. We established a multidisciplinary Shared Medical Appointment and Readiness Teaching (SMART) clinic for all gynecologic oncology patients initiating chemotherapy with platinum- and taxane-based regimens. This model of care provides patient education within a framework of social support that empowers patients. We developed a standardized chemotherapy education presentation, and also provided patients with a tool kit that consisted of chemotherapy drug education, a guide to managing side effects, advanced directives and center contact information. Surveyed patients reported being highly satisfied with the group visit and would recommend SMA to other patients. Our preliminary data analysis revealed that SMART visits decreased wait time and increased value-added time for patients. Conclusions: SMAs for oncology patients initiating chemotherapy is both novel and feasible. A patient centric model, collaboration of multidisciplinary team members, and timely responsiveness to constructive feedback are essential to the successful integration of SMAs in an academic center.

IMPROVING CARDIAC PATIENT CARE BY UTILIZING RN’S AND NP’S TO THEIR FULL SCOPE OF PRACTICE

Cardiac EASE (Ensuring Access and Speedy Evaluation) clinic is a multidisciplinary general cardiology clinic at a large tertiary care hospital, designed to decrease wait times for cardiac consults and improve efficiencies. By participating in Access Improvement Measures, greater efficiencies were achieved by utilizing RN’s to their full scope of practice. The purpose is to share how the Cardiac EASE Clinic achieved RN’s and NP’s to work to full scope of practice resulting in improved patient outcomes and clinic capacity.Algorithms, policies and procedures were developed to empower RN’s to perform roles which traditionally had been NP roles. These were endorsed by cardiologists and leadership to enable RN’s to complete these roles. Nurse Practitioners were then able to be utilized within cardiology to improve patient outcomes in new cardiac clinics and programs.With RN’s working to full scope of practice, 1408 new cardiac referrals were seen in the Cardiac EASE clinic in 2013. Referrals were for chest pain (434), palpitations (213), atrial fibrillation (164), coronary artery disease assessment (174) arrhythmia (78), Presyncope/syncope (112), arrhythmia (78), shortness of breath (49), Valvular heart disease (44), congestive heart failure (32) and pre-operative consultation(8). Patients were seen within 28.3 days + 27.1 days(mean). New NP roles were developed to expand capacity within the Cardiac EASE clinic, Atrial Fibrillation Clinic and Cardiac Rehabilitation program.Identifying inefficiencies and ways for RN’s to work to full scope of practice; enabled NP’s to also work to full scope of practice resulting in improved cardiac patient care without increasing the funding model. Cardiac EASE (Ensuring Access and Speedy Evaluation) clinic is a multidisciplinary general cardiology clinic at a large tertiary care hospital, designed to decrease wait times for cardiac consults and improve efficiencies. By participating in Access Improvement Measures, greater efficiencies were achieved by utilizing RN’s to their full scope of practice. The purpose is to share how the Cardiac EASE Clinic achieved RN’s and NP’s to work to full scope of practice resulting in improved patient outcomes and clinic capacity. Algorithms, policies and procedures were developed to empower RN’s to perform roles which traditionally had been NP roles. These were endorsed by cardiologists and leadership to enable RN’s to complete these roles. Nurse Practitioners were then able to be utilized within cardiology to improve patient outcomes in new cardiac clinics and programs. With RN’s working to full scope of practice, 1408 new cardiac referrals were seen in the Cardiac EASE clinic in 2013. Referrals were for chest pain (434), palpitations (213), atrial fibrillation (164), coronary artery disease assessment (174) arrhythmia (78), Presyncope/syncope (112), arrhythmia (78), shortness of breath (49), Valvular heart disease (44), congestive heart failure (32) and pre-operative consultation(8). Patients were seen within 28.3 days + 27.1 days(mean). New NP roles were developed to expand capacity within the Cardiac EASE clinic, Atrial Fibrillation Clinic and Cardiac Rehabilitation program. Identifying inefficiencies and ways for RN’s to work to full scope of practice; enabled NP’s to also work to full scope of practice resulting in improved cardiac patient care without increasing the funding model.

STRIVING FOR GOLD: A GLANCE AT CARDIAC SURGERY PERFORMANCE ROUNDS

Cardiac EASE (Ensuring Access and Speedy Evaluation) clinic is a multidisciplinary general cardiology clinic at a large tertiary care hospital, designed to decrease wait times for cardiac consults and improve efficiencies. By participating in Access Improvement Measures, greater efficiencies were achieved by utilizing RN’s to their full scope of practice. The purpose is to share how the Cardiac EASE Clinic achieved RN’s and NP’s to work to full scope of practice resulting in improved patient outcomes and clinic capacity. Algorithms, policies and procedures were developed to empower RN’s to perform roles which traditionally had been NP roles. These were endorsed by cardiologists and leadership to enable RN’s to complete these roles. Nurse Practitioners were then able to be utilized within cardiology to improve patient outcomes in new cardiac clinics and programs. WithRN’s working to full scope of practice, 1408new cardiac referrals were seen in the Cardiac EASE clinic in 2013. Referrals were for chest pain (434), palpitations (213), atrial fibrillation (164), coronary artery disease assessment (174) arrhythmia (78), Presyncope/syncope (112), arrhythmia (78), shortness of breath (49), Valvular heart disease (44), congestive heart failure (32) and pre-operative consultation(8). Patients were seen within 28.3 days + 27.1 days(mean).NewNP roles were developed to expand capacitywithin theCardiac EASE clinic, Atrial FibrillationClinic and Cardiac Rehabilitation program. Identifying inefficiencies and ways for RN’s to work to full scope of practice; enabled NP’s to also work to full scope of practice resulting in improved cardiac patient care without increasing the funding model.

Prenatal diagnosis in haemophilia A: experience of the genetic diagnostic laboratory.

The paper describes the experience of the Genetic Diagnostic Laboratory in prenatal testing for haemophilia A, an X-linked recessive disease caused by mutations in the F8 gene. Knowledge of a familial mutation prior to pregnancy can benefit prenatal diagnosis and decrease wait time for molecular testing during pregnancy. This is a retrospective review of a series of pregnant women who pursued F8 gene testing from December 1997 through May 2012, highlighting three cases, which demonstrate the technical complexities of analysis and the implications of not knowing carrier status prior to pregnancy. Mutations of the F8 gene were detected in affected males, obligate female carriers and suspected female carriers by DNA sequencing, inverse-PCR, qRT-PCR, Southern blot and exonic dosage analysis. The same methods were used to analyse prenatal samples from obligate or suspected female carriers upon request. Maternal cell contamination studies were performed for all prenatal samples analysed. Ninety-nine women pursued F8 testing during pregnancy, either for carrier status alone or carrier status and prenatal diagnosis. Ninety-one women (91%) requested carrier testing because they did not know their F8 mutation carrier status prior to pregnancy. Eight women requested prenatal diagnosis only, and only 4 of these were aware of their mutation status. Thirty-seven individuals were found to be mutation carriers. Forty-two prenatal samples were received for prenatal diagnosis. In total 21 foetuses were identified as mutation carriers. Mutation detection was complex and increased the turnaround time in some cases. Only four of 99 women who submitted samples for F8 testing were aware of their F8 mutation status prior to pregnancy. Knowledge of F8 mutation status prior to pregnancy allows for efficient prenatal diagnosis, when desired. Thus, preconception genetic counselling is required to inform patients of the available options and the complex and time-consuming nature of F8 testing.

Educational ExhibitAbstract No. 359 - Employing workflow analysis to reduce wait-times for IR patients

Educational ExhibitAbstract No. 359 - Employing workflow analysis to reduce wait-times for IR patients

Key Elements of Highly Effective Teams

The Council on Medical Student Education in Pediatrics (COMSEP) is an organization that values — and appreciates the benefits of — teams. COMSEP's best work comes as a result of highly effective teamwork. A team is more than 1 person working together toward a common goal. Therefore, every physician is on multiple teams, ranging from a small team of himself or herself and a patient and family, to primary care medical home teams, to inpatient care teams with various levels of trainees and different professionals, to clinical and basic science research teams, to hospital boards, university committees, and organized community initiatives. Knowing the key elements of highly effective teams is relevant to every clinician, no matter where he or she practices. In health care, team communication failures contribute to health care errors.1 Effective teams decrease length of stay, result in fewer unanticipated admissions, improve coordination of care, decrease wait times, increase patient satisfaction, and improve health outcomes.2 The literature on teams is complex. A wide variety of conceptual frameworks3 have been developed independently, and as a result, they are not aligned with each other.4 In the health care literature specifically, a large number of team models have been proposed.5–7 In this article, we present a novel way to think about team effectiveness that is easy to remember and can be used to set your team up for success and resolve common barriers. Drawing on the business, … Address correspondence to Susan L. Bannister, MD, MEd, Department of Paediatrics, Alberta Children’s Hospital, 2888 Shaganappi Trail NW, Calgary AB, T3B 6A8, Canada. E-mail: susan.bannister{at}albertahealthservices.ca

Patients’ Stories of Interprofessional Whole-Person Care

Objectives: Interprofessional whole-person care has been depicted as being able to enhance patient health outcomes, increase health care provider satisfaction with care delivery, lower health care spending and decrease wait times for receiving care. Limited research has been conducted into exploring patients’ experiences of being recipients of this type of care. The objective of this oral presentation is to disseminate findings of a Master of Nursing study through patients’ stories of experience receiving care on aunit where inter professional care is practiced.Methods: Three participants underwent a two step data collection process: a one hour semi-structured interview and a 30 minute symbolic image artistic exercise, as adapted from Schwind’s Narrative Reflective Process. Participants were invited to describe how they experienced receivingcare from an interprofessional team and whether or not they believed whole-person care was delivered to them. Collected data are being analyzed using Clandinin and Connelly’s Narrative Inquiry approach of three dimensionalspace, temporality, sociality and place.Results: The emerging results suggest that participants express satisfaction with the care they received from the interprofessional team on their unit. Their stories indicate that strong interprofessional team-work can contribute to patient satisfaction in care received. For these teams to be successful, from the patients’ point of view, there needs to be: better communication between care providers, greater involvement of the patient in decision making, proper identification of who comprises the teams, andconsistency in team composition.Conclusion: By acknowledging experiences and feelings ofpatients who have received care from an interprofessional team, there is potential to increase sustainability of these teams. The data generated through this study can potentially help health care providers, who are members of interprofessional teams, to deliver more effective, comprehensive whole-personcare within health care institutions.

Impact of an acute care surgery service on timeliness of care and surgeon satisfaction at a Canadian academic hospital: a retrospective study

IntroductionIn January 2012 an acute care surgery (ACS) model was introduced at St. Paul’s Hospital, Saskatoon, Saskatchewan. The goal of implementing an ACS service was to improve the delivery of care for emergent, non-trauma surgical patients. We examined whether the ACS model improved wait time to surgery, decreased the proportion of surgeries performed after hours, and shortened post-surgical length of stay. We also assessed whether the surgeons working in an ACS system had higher on-call satisfaction than surgeons working in a non- ACS system.MethodsA retrospective pre-post analysis was performed using data from the Discharge Database and the Organizing Medical Networked Information database. Surgeon satisfaction was evaluated using a questionnaire that was mailed to all general surgeons in Saskatoon.ResultsAn ACS service significantly reduced wait time to surgery for patients with all acute general surgery diagnoses from 221 minutes to 192 minutes (ρ = 0.015; CI = 5.8-52.2). Post-surgery length of stay for patients operated on for acute appendicitis, or acute cholecystitis was not reduced. On average, patients with bowel obstruction had increased length of stay following ACS service implementation. Most surgeries in our study were performed between 16:00 hours and 08:00 hours but the introduction of an ACS significantly reduced the number of afterhours surgeries (60.0% vs. 72.6%) (ρ < 0.0001). Our survey had a response rate of 75%. Overall, surgeons on an ACS service had greater satisfaction with the organization of their call schedule than surgeons not on an ACS service.ConclusionIntroduction of an ACS service in Saskatoon has decreased wait time to surgery and reduced the proportion of afterhours emergency surgeries, with no reduction in the length of post-surgery hospital stay. Satisfaction may be higher for surgeons in an ACS service.

Predictors of non-diagnostic cytology in surgeon-performed ultrasound guided fine needle aspiration of thyroid nodules.

BackgroundFine needle aspiration (FNA) is the standard of care for the diagnostic work-up of thyroid nodules but despite its proven utility, the non-diagnostic rate for thyroid FNA ranges from 6-36%. A non-diagnostic FNA is problematic for the clinician and patient because it can result in repeated procedures, multiple physician visits, and a delay in definitive treatment. Surgeon-performed FNA has been shown to be safe, cost-effective, as accurate as those performed by other clinicians, and has the added benefit of decreasing wait times to surgery. Several studies have examined rates and factors that may be predictive of a non-diagnostic cytology in non-surgeon FNA, but none have evaluated this in surgeon-performed thyroid FNA. If these factors are unique in surgeon-performed vs. non-surgeon performed thyroid FNA, then patients may be more appropriately triaged to FNA by alternate clinicians.ObjectivesThe purpose of this study was to determine the rate and factors predictive of a non-diagnostic FNA in surgeon performed ultrasound-guided FNA of thyroid nodules.MethodsWe conducted a retrospective review of all adult patients who underwent thyroid FNA by a staff, fellow, or resident Otolaryngologist at the University of Alberta between January 2011 and June 2013. Factors analyzed included patient factors, thyroid characteristics, nodule characteristics, and surgeon level of training and experience. Univariate and multivariate binary logistic regression analysis were performed.Results131 patients (180 nodules) were reviewed. The non-diagnostic rate was 23%. Nodules with predominant cystic component, those less than 1 cm, and resident-performed FNA were associated with non-diagnostic cytology (p = 0.001, p = 0.02, p = 0.04 respectively). A cystic nodule was the only independent predictor of non-diagnostic FNA on multivariate analysis (OR = 4.441, 95% CI [1.785-11.045], p = 0.001).ConclusionsThe rate of non-diagnostic thyroid FNA performed by a surgeon with ultrasound guidance is similar to other clinicians. A cystic nodule is a strong independent predictor of non-diagnostic cytology. Non-cystic nodules may particularly benefit from surgeon-performed thyroid FNA due to the high diagnostic rate and potential for earlier definitive management.

Comparison of Emergency Nurses Association Emergency Severity Triage and Australian Emergency Mental Health Triage Systems for the Evaluation of Psychiatric Patients

The use of a triage system in the emergency department allows for the ability to reliably assign patients for treatment within a short amount of time in order to prioritize and treat on the basis of patients injury and illness. A 5 point triage system has been shown to have the highest correlation with effective resource utilizations, lower time to be seen and treatment times, and admission or release outcomes for patients. The problem is, however, that these triage scales were developed on the basis of physical illness and not on the ever-increasing number of patients who present with mental illness. This article compares one physical and one specific mental illness-based triage system to measure the differences in times to be seen by a physician. It found that the specialized psychiatric triage system decreased wait times and allowed symptoms to be addressed sooner for patients presenting with psychiatric complaints.

A novel community-based delivery model to combat cancer disparities

Implementation lessons•It is hypothesized that this delivery model can decrease wait times for diagnosis and treatment of cancer, increase awareness and knowledge of cancer prevention and treatment, and foster trust with providers and patients from vulnerable communities.•Involving oncologists in clinical diagnosis at community health centers can link specialty care more closely to vulnerable communities.•Funding for this type of clinical innovation is currently limited to institutional and philanthropic sources. A shift in the academic and public sector funding paradigms may be required to enable implementation on a broader level.

Improving efficiencies in a hospital-based hematology outpatient service.

165 Background: The Hematology Hospital Outpatient service at Rochester Methodist Hospital provides ambulatory outpatient care to patients who would normally be hospitalized on our inpatient services due to cytopenias and need for infusion/transfusion support. A quality project was conducted to streamline our process and decrease wait times. Methods: This project was a part of a Mayo Lean Collaborative initiative to increase customer satisfaction and eliminate waste. The first step was to collect baseline measurements to capture the non-value added waiting time of our entire outpatient process. These benchmark times were collected from 65 patients over 4 days. We evaluated these wait times to identify gaps in care and factors contributing to delays in our process. Data collected "before and after" each implementation phase determined if the change was beneficial. Results: Through our data collection, one major area of opportunity we identified was the wait time for CBC results. At baseline, patients were waiting in a room for 61.9 minutes for lab results. A major contributor to delay was the lack of carriers to send blood samples through the tube system being stocked in the outpatient area. We also discovered that the time from when the sample was placed in the carrier to the time it arrived in our lab was significant. Through a process analysis it was identified that the CBC tubes were being sent to a central lab prior to their final destination in the Hematology lab. We were able to re-route our CBCs directly to the hem lab. Data collected after the intervention showed we were receiving results at 51 minutes, therefore, eliminating 10.9 minutes off of an appointment. We also identified additional opportunities such as pre-assigning rooms, scheduling, exam room organization, and communication that were able to be addressed. Conclusions: As a result of this lean collaborative project we reduced patient wait time by 20.1 minutes and increased patient satisfaction. We were able to order interventions sooner thereby increasing patient safety. By process analysis, we identified multiple areas in our process that could be shortened with no additional cost.

Advances in pre-hospital management of diving accidents in the Mediterranean area from 1991 to 2008

The field of urgent care medicine offers an additional medical pathway for patients who have immediate, but non-life-threatening, medical concerns. Urgent care medicine offers a more varied set of resources and services than a physician office setting, with more flexible hours. This gives patients an opportunity to not have to go to the emergency department for non-emergent care. As a newer specialty within the medical field, certain roles of healthcare providers other than physicians are becoming established, including the advanced practice provider (APP). An APP is a nurse practitioner or a physician assistant, who is licensed to treat under the supervision of a physician. Nurse practitioners’ (NP) and physician assistants’ (PA) role in urgent care is often seen as an effective, lower cost option to manage common acute minor illnesses seen in the community. Benefits to utilizing APPs in urgent care include decreasing costs to both the patient and health system, enhancing the physician's ability to see more patients, and decreasing wait times, all while continuing to maintain high standards of care. The goal of the authors within this publication is to discuss urgent care as a specialty and further explore the role of advanced practice providers within this setting.

Disparities in Policies, Practices and Rates of Pediatric Kidney Transplantation in Europe

We aimed to provide an overview of kidney allocation policies related to children and pediatric kidney transplantation (KTx) practices and rates in Europe, and to study factors associated with KTx rates. A survey was distributed among renal registry representatives in 38 European countries. Additional data were obtained from the ESPN/ERA-EDTA and ERA-EDTA registries. Thirty-two countries (84%) responded. The median incidence rate of pediatric KTx was 5.7 (range 0−13.5) per million children (pmc). A median proportion of 17% (interquartile range 2−29) of KTx was performed preemptively, while the median proportion of living donor KTx was 43% (interquartile range 10−52). The median percentage of children on renal replacement therapy (RRT) with a functioning graft was 62%. The level of pediatric prioritization was associated with a decreased waiting time for deceased donor KTx, an increased pediatric KTx rate, and a lower proportion of living donor KTx. The rates of pediatric KTx, distribution of donor source and time on waiting list vary considerably between European countries. The lack of harmonization in kidney allocation to children raises medical and ethical issues. Harmonization of pediatric allocation policies should be prioritized.

Beat the clock! Wait times and the production of ‘quality’ in emergency departments

Emergency care in large urban hospitals across the country is in the midst of major redesign intended to deliver quality care through improved access, decreased wait times, and maximum efficiency. The central argument in this paper is that the conceptualization of quality including the documentary facts and figures produced to substantiate quality emergency care is socially organized within a powerful ruling discourse that inserts the interests of politics and economics into nurses' work. The Canadian Triage and Acuity Scale figures prominently in the analysis as a high-level organizer of triage work and knowledge production that underpins the way those who administer the system define, measure and evaluate emergency care processes, and then use this information for restructuring. Managerial targets and thinking not only dominate the way emergency work is understood, determined, and controlled but also subsume the actual work of health-care providers in spaces called 'wait times', where it is systematically rendered 'unknowable'. The analysis is supported with evidence from an extensive institutional ethnography that shows what nurses actually do to manage the safe passage of patients through their emergency care process starting with the work of triage nurses.

PTH-132 Iron Deficiency Anaemia Nurse Led Clinic: Audit of 1st Year

IntroductionIron deficiency anaemia accounts for 4–13% of gastrointestinal referrals occurring in 2–5% of adult men and post menopausal women. Current guidelines suggest that the work up of asymptomatic anaemia remains...