Decrease Wait Times Research Articles

Successful use of telemedicine for evaluation of infantile hemangiomas during the early COVID-19 pandemic: A cross-sectional study.

The COVID-19 pandemic prompted a rapid expansion in the use of telemedicine. This study aimed to assess the experiences of hemangioma specialists utilizing telemedicine during the COVID-19 pandemic to evaluate and manage infantile hemangiomas (IH), including perceived effectiveness of different modalities and barriers to care delivery. Multicenter cross-sectional study asking providers to describe their experiences using telemedicine for initial evaluation of IH from March to September 2020. The study included 281 patients from 15 medical centers internationally. Median time from referral to evaluation was 17 days. Median physician confidence in performing evaluations via telemedicine was 95.0 (IQR 90.0-100.0). Most evaluations were performed via video communication with photographs or audio communication with photographs; when not initially available, photographs were requested in 51.4%. Providers preferred follow-up modalities that included photographs. Physicians with extensive expertise in managing IH are confident in their abilities to assess and manage IH via telemedicine including initiating treatment in patients without risk factors for beta-blocker therapy. There was a preference for hybrid modalities that included photographs. The data suggest that telemedicine can be effective for managing IH and may decrease wait times and improve specialist reach to underserved areas.

Predicting the target specialty of referral notes to estimate per-specialty wait times with machine learning

BackgroundCurrently, in Canada, existing health administrative data and hospital-inputted portal systems are used to measure the wait times to receiving a procedure or therapy after a specialist visit. However, due to missing and inconsistent labelling, estimating the wait time prior to seeing a specialist physician requires costly manual coding to label primary care referral notes.MethodsIn this work, we represent the notes using word-count vectors and develop a logistic regression machine learning model to automatically label the target specialist physician from a primary care referral note. These labels are not available in the administrative system. We also study the effects of note length (measured in number of tokens) and dataset size (measured in number of notes per target specialty) on model performance to help other researchers determine if such an approach may be feasible for them. We then calculate the wait time by linking the specialist type from a primary care referral to a full consultation visit held in Ontario, Canada health administrative data.ResultsFor many target specialties, we can reliably (F1Score ≥ 0.70) predict the target specialist type. Doing so enables the automated measurement of wait time from family physician referral to specialist physician visit. Of the six specialties with wait times estimated using both 2008 and 2015 data, two had a substantial increase (defined as a change such that the original value lay outside the 95% confidence interval) in both median and 75th percentile wait times, one had a substantial decrease in both median and 75th percentile wait times, and three has non-substantial increases.ConclusionsAutomating these wait time measurements, which had previously been too time consuming and costly to evaluate at a population level, can be useful for health policy researchers studying the effects of policy decisions on patient access to care.

Electromagnetic Navigation Transthoracic Nodule Localization for Minimally Invasive Thoracic Surgery.

The increased use of chest computed tomography (CT) has led to an increased detection of pulmonary nodules requiring diagnostic evaluation and/or excision. Many of these nodules are identified and excised via minimally invasive thoracic surgery; however, subcentimeter and subsolid nodules are frequently difficult to identify intra-operatively. This can be mitigated by the use of electromagnetic transthoracic needle localization. This protocol delineates the step-by-step process of electromagnetic localization from the pre-operative period to the postoperative period and is an adaptation of the electromagnetically guided percutaneous biopsy previously described by Arias et al. Pre-operative steps include obtaining a same day CT followed by the generation of a three-dimensional virtual map of the lung. From this map, the target lesion(s) and an entry site are chosen. In the operating room, the virtual reconstruction of the lung is then calibrated with the patient and the electromagnetic navigation platform. The patient is then sedated, intubated, and placed in the lateral decubitus position. Using a sterile technique and visualization from multiple views, the needle is inserted into the chest wall at the prechosen skin entry site and driven down to the target lesion. Dye is then injected into the lesion and, then, continuously during needle withdrawal, creating a tract for visualization intra-operatively. This method has many potential benefits when compared to the CT-guided localization, including a decreased radiation exposure and decreased time between the dye injection and the surgery. Dye diffusion from the pathway occurs over time, thereby limiting intra-operative nodule identification. By decreasing the time to surgery, there is a decrease in wait time for the patient, and less time for dye diffusion to occur, resulting in an improvement in nodule localization. When compared to electromagnetic bronchoscopy, airway architecture is no longer a limitation as the target nodule is accessed via a transparenchymal approach. Details of this procedure are described in a step-by-step fashion.

Abstract 247: Reducing Repeat Echocardiography Testing In Hospitalized Patients

Background/Problem: Medicare spends more than $900 million annually on cardiac echocardiography. Despite the development of appropriate use criteria for echocardiography to limit inappropriate testing, at least 5% to 20% of studies may remain inappropriate. For simple indications or repeat serial exams, a brief, limited transthoracic echocardiogram (TTE) with minimal views and measurements may answer the diagnostic question. In the current state, there are no guidelines of when to order a comprehensive TTE vs limited TTE or a reminder in our electronic health record system (EPIC) that a TTE has already been done. Few physicians are aware of the possibility of even ordering a limited TTE. Intervention: Patient encounters with repeat comprehensive TTE orders were randomized (in real-time) to the intervention, an electronic reminder or best practice alert (BPA), or control, no reminder. The reminder interrupted the ordering process and notified the ordering provider that a comprehensive TTE result was available within the prior 3 months. The reminder provided a link to the result and offered a limited study order as an alternative. The primary outcome was the number of full versus limited TTEs. Results: Over one year in a tertiary care medical center, 3314 patient encounters were randomized to the intervention (N=1661) with a BPA or control group (N=1653) without a reminder. In the control group, there were 1803 full TTE and 222 limited TTE. In the intervention group, there were 1647 full TTE and 379 limited TTE. Analysis with chi-square testing resulted in a p<0.0001. Conclusion: In this randomized trial, a BPA or interruptive reminder in an EHR reduced repeat comprehensive echo testing. The reduced repeat testing can decrease the cost of care, increase access by decreasing wait times for other patients, and potentially improve the patient experience by avoiding any discomfort associated with testing.

Impact of quality improvement initiatives to improve CKD referral patterns: a systematic review protocol

IntroductionChronic kidney disease (CKD) is a global-health problem. A significant proportion of referrals to nephrologists for CKD management are early and guideline-discordant, which may lead to an excess number of...

Living Donor Liver Transplantation vs. Split Liver Transplantation Using Left Lateral Segment Grafts in Pediatric Recipients: An Analysis of the UNOS Database.

Split and LDLT in pediatric patients have the potential to decrease wait times and waitlist mortality. Using UNOS-STAR data, we compared outcomes of pediatric patients undergoing LDLT and SLT using LLS grafts. The baseline characteristics and post-operative outcomes were compared between groups. Actuarial graft and patient survival were analyzed with Kaplan-Meier curves. Between 2010 and 2019, 911 pediatric LT were included in the analysis (LD graft group, n = 508, split graft group, n = 403). LD graft recipients spent more time on the waitlist vs. the split graft group (60 (22–138) days vs. 46 (16–108) days; p = 0.007). LD recipients had a lower rate of graft failure, found in 9.8% of patients compared with 14.6% in the split graft group (p = 0.02). HAT was the most common graft failure cause, with similar rates. Graft and patient survival at 1-, 3-, and 5-years was comparable between LDLT and SLT. In subgroup analyses, patients with biliary atresia, those ≤10 kg or ≤10 years old receiving an LD graft showed improved graft survival. In conclusion, LDLT is associated with a lower rate of graft failure in pediatric patients. The use of LLS regardless of the type of donor is a safe way to facilitate access to transplantation to pediatric patients with acceptable short and long-term outcomes.

EP297: Overview of pediatric genetic counseling clinic models and genetic counselors' perceptions of them

eP297: Overview of pediatric genetic counseling clinic models and genetic counselors' perceptions of them

306 In the COVID Aftermath, Using an Innovative Collaborative Approach to Improve Wait Times for Skin Cancer Patients

Abstract COVID-19 led to drastic reductions in non-urgent medical visits and cancer care. Surgical patient backlogs mean new strategies are required to decrease wait times and administrative costs whilst improving patient outcomes. We review the impact of combined speciality Plastic Surgery and Dermatology 2 week-wait (2ww) clinics on wait times and hospital attendances and associated cost implications when compared to the single speciality clinics. Retrospective analysis comparing Plastic surgery (PS) and Dermatology (DM) 2ww clinics against combined Dermatology and Plastic surgery (DP) clinics across the same 3-month period in 2018 and 2019 at a single UK tertiary centre. 283 patients reviewed across the same 3-month period in 2018 and 2019 (PS n = 53, DM n = 158, PD n = 72). PD reviewed most patients per clinic (Averages: PD n = 18.0, PS n = 8.8, DM n = 12.1). Hospital attendance decreased from 1.84 to 1.51 visits. 42.9% of excisional biopsies were performed on the same day as initial assessment compared to 18.0% in PS/DM clinics. Referral to surgery time decreased from 67.7days to 50.4 days, and tertiary assessment to surgery from 49.5days to 36.9days. PD attracted tariffs of up to £29.78 more per patient. Combined clinics see more patients and attract higher tariffs per patient, whilst reducing outpatient attendances and wait times to surgery. This has significant cost-saving implications whilst optimising cancer care.

Fast Neuro: A Care Model to Expedite Access to Neurology Clinic.

We set out to improve outpatient neurology access while reducing patient volume in the emergency department (ED) for nonemergent neurologic complaints. We created a rapid access model, University of California Los Angeles (UCLA) Fast Neuro, for patients referred from affiliated EDs to outpatient neurology, enabling appointments within 1 week of referral. Rapid access appointments were also available to established neurology patients with urgent concerns. Fast Neuro was built to reduce nonemergent neurologic care in the ED, improve outpatient neurology access, and avoid use of inpatient neurology services for nonemergent consults. The volume of referrals and neurology consults from the ED and wait time from referral to appointment were measured. Surveys were conducted at 3 and 6 months to assess satisfaction with the model by all stakeholders. From January 2019 through January 2021, 201 patients were referred to outpatient neurology through UCLA Fast Neuro. Wait time for an outpatient neurology appointment was reduced from the prior period by 82.5% (7.0 ± 5.5 vs 40 ± 4.1 days). The number of nonemergent consults from the ED was reduced by 60% (4.1 ± 1.9/mo vs 10.3 ± 1.7/mo). Surveys showed wide acceptance of the new model with 92% of attending physicians and advanced practice providers and 89% of residents endorsing that UCLA Fast Neuro patients did not detract from their clinic experience. UCLA Fast Neuro improved ED throughput, reduced inpatient neurology consults from the ED, and decreased wait times for outpatient neurology appointments without using the inpatient neurology service for nonurgent consults. UCLA Fast Neuro was successful. Exploration of how to scale and implement the model of access more broadly is warranted.

Interval Valued Neutrosophic Sets and Multi-Criteria Decision Making for Sustainable Mobile Healthcare Promotion

The use of health mobile websites or apps on smartphones like mobile-phones has made it possible for users to have quick, inexpensive access to the services of licensed medical professionals. As a result, mobile health care has the potential to lessen the burden on the healthcare system by lowering costs, decreasing wait times, and maximizing the effectiveness of available resources. In order to foster the long-term growth of healthcare infrastructure. This paper introduce the interval valued neutrosophic sets (IVNSs) to overcome the uncertainty. The IVNSs is combined with the MCDM methodology such as TOPSIS method. The TOPSIS technique is used to order the options. In addition to assisting with the selection of the best mobile health care option, this methodology may be used to close the performance gap between competing products and meet customer expectations. There were four distinct categories of mobile health care products investigated.

Abstracts for the 40th emergencies in medicine conference

Abstracts for the 40^th emergencies in medicine conference

P008 A Novel Smartphone Application to Reduce Infusion Suite Wait Times.

Patients with inflammatory bowel disease (IBD) are often treated with biologic medications that require visits to an infusion suite. Due to the high cost of biologics, they are not mixed and released from the pharmacy until patient arrival. This typically leads to long wait times after patient check in. An investigator-developed novel smartphone application (app) titled Almost There was created to reduce wait times through the use of geofences to notify the infusion suite when patients are nearing their destination (the hospital). Our aim was to perform a pilot study to assess the feasibility of Almost There for patients with IBD coming for infusions at a rural academic medical center. Adult patients with Crohn's disease (CD) or ulcerative colitis (UC) currently receiving intravenous biologic therapy were recruited for this pilot study. Patients received instructions on how to download the app onto their smartphone. Patients activated the application prior to leaving their homes and answered standard screening questions to assess for active infections. Using geofences, the app automatically notified the infusion suite when the patient was within 10 miles of the hospital. The infusion suite alerted the pharmacy who immediately proceeded with medication preparation. Patients completed surveys upon arrival to the infusion suite collecting basic demographics and disease information, perceived wait times for that visit and previous visits prior to using the app. The infusion suite staff recorded actual wait times from check in to medication administration. The app was trialed successfully for 12 total visits among 9 patients (5 CD, 4 UC). 78% of app users were 25-44 years old and 22% were 45 years and older. 56% of patients were receiving infliximab and 44% were receiving vedolizumab. 11 patients were recruited and 9 patients out of 11 were able to successfully use the app. Reasons for app failure included one user who forgot their phone at home, one with loss of cell service, and one app malfunction. The median actual wait time from when patients arrived at the infusion suite to the start of the infusion was 38-40 minutes. In 67% of visits, there was decreased perceived wait time for patients using the app compared to their prior visits. When using the app, perceived wait times were shorter than actual wait times in 75% percent of patients. In this pilot feasibility study, the Almost There app led to decreased perceived wait times for IBD patients coming for biologic infusions. The application was not effective for 18% of patients for a variety of reasons. If this or a similar app was improved to allow for more consistent usability it should be studied compared to a control group to evaluate if it leads to decreased wait times for any medical infusion.

S3314 A Novel Smartphone Application to Reduce Infusion Suite Wait Times

Introduction: Patients with inflammatory bowel disease (IBD) are often treated with biologic medications that require visits to an infusion suite. Due to the high cost of biologics, they are not mixed and released from the pharmacy until patient arrival. This typically leads to long wait times after patient check in. A novel smartphone application (app) titled Almost There was created to reduce wait times through the use of geofences to notify the infusion suite when patients are nearing their destination. We performed a pilot study to assess the feasibility of Almost There for patients with IBD coming for infusions at a rural academic medical center. Methods: Adult patients with Crohn’s disease (CD) or ulcerative colitis (UC) currently receiving intravenous biologic therapy were recruited for the study. Patients received instructions on how to download the app onto their smartphone. Patients activated the application prior to leaving their homes and answered standard screening questions to assess for active infections. Using geofences, the app automatically notified the infusion suite when the patient was within 10 miles of their destination. The infusion suite alerted the pharmacy who immediately proceeded with medication preparation. Patients completed surveys upon arrival to the infusion suite collecting basic demographics and disease information, perceived wait times for that visit and previous visits prior to using the app. The infusion suite staff recorded actual wait times from check in to medication administration. Results: The app was trialed successfully for 12 total visits among 9 patients (5 CD, 4 UC). 78% of app users were 25-44 years old and 22% were 45 years and older. 56% of patients were receiving infliximab and 44% were receiving vedolizumab. 11 patients were recruited and 9 patients out of 11 were able to successfully use the app. Reasons for app failure included one user who forgot their phone at home, one with loss of cell service, and one app malfunction. In 67% of visits, there was decreased perceived wait times with the app (Figure 1). When using the app, perceived wait times were shorter than actual wait times in 75% percent of patients. Conclusion: The Almost There app led to decreased perceived wait times for IBD patients coming for biologic infusions. The application was not effective for 18% of patients for a variety of reasons. If this or a similar app was improved to allow for more consistent usability, it could allow for decreased wait times for any medical infusion.Figure 1.: Comparing Perceived Wait Times to Actual Infusion Suite Wait Times X axis: Patient Visits Y axis: Time (minutes) Legend: Blue - Perceived wait time without app Orange - Perceived wait time with app Gray - Actual wait time.

Patient Perspectives on Telemedicine During the COVID-19 Pandemic.

Patients received care over telemedicine during the COVID-19 pandemic, and their perspective is useful for hand surgeons. Online surveys were sent October-November 2020 to 497 patients who received telemedicine care. Questions were free-response and multi-item Likert scales asking about telehealth in general, limitations, benefits, comparisons to in-person visits, and opinions on future use. The response rate was 26% (n = 130). Prior to the pandemic, 55% had not used telemedicine for hand surgery consultation. Patients liked their telemedicine visit and felt their provider spent enough time with them (means = 9/10). In all, 48% would have preferred in-person visits despite the pandemic, and 69% would prefer in-person visits once the pandemic concludes. While 43% had no concerns with telemedicine, 36% had difficulties explaining their symptoms. Telemedicine was easy to access and navigate (M = 9/10). However, 23% saw telemedicine of limited value due to the need for an in-person visit soon afterward. Of these patients, 46% needed an in-person visit due to inadequate physical examination. Factors that make telemedicine more favorable to patients included convenience, lack of travel, scheduling ease, and time saved. Factors making telemedicine less favorable included need for in-person examination or procedure, pain assessment, and poor connectivity. There was no specific appointment time the cohort preferred. Patient recommendations to improve telemedicine included decreasing wait times and showing patient queue, wait time, or physician status online. Telemedicine was strongly liked by patients during the COVID-19 pandemic. However, nearly 70% of patients still preferred in-person visits for the future.

A Quality Improvement Initiative to Provide Timely Central Vascular Access in a Neonatal Intensive Care Unit.

Timely central venous access is essential in the care of critically ill neonates. Peripherally inserted central catheters (PICCs) are the preferred form of central venous access when umbilical venous catheters cannot be placed or are discontinued. However, time delays increase risk for injury from peripheral intravenous lines and may contribute to inconsistent delivery of necessary fluids and medications. The aim of this quality improvement project was to decrease wait times for PICC placement in the neonatal intensive care unit (NICU). A unit-based PICC team was developed consisting of NICU nurses and attending neonatologists and implemented in 2 phases. Data were collected from chart reviews before, during, and after implementation of the team. We tracked time between PICC order and placement and number of attempts. Hospital metrics on peripheral intravenous line infiltrations and central line-associated blood stream infection were also monitored. At the end of the project, we continued tracking outcomes to determine whether gains would be sustained past the project period. Implementation of a unit-based interdisciplinary specialty team led to a 50% reduction in mean PICC wait times from 1.2 days to 0.58 days. Benefits of the initiative were sustained past the initial project period. The development of a dedicated, local team played a key role in improving vascular access in the NICU. Proximity of specialized teams provides a solution to address gaps in care in the NICU.

Implementation and Monitoring of a Telemedicine Model in Acromegalic Outpatients in a Low-Income Country During the COVID-19 Pandemic.

Background: Telemedicine is a resource to provide health care to patients social distancing and prevent their exposure to the risk of contamination by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in medical-hospital settings. This study evaluated a virtual model of care in acromegalic patients. Methods: We recruited 78 acromegalic patients, 65% female, median age 63 years. Outpatient management was remodeled to simplify access to care by (1) adoption of virtual meetings; (2) collection of blood samples at home; (3) abolishment of printed prescription and provision of electronic files directly to central pharmacy; and (4) drugs delivered to patients' home. Patients and physicians filled electronic surveys 48 h after each consultation. Results: The patients expressed satisfaction with convenience (91.1%), decreased wait time (85.1%), and saving money (79.2%) compared to face-to-face visits. Most patients felt supported by the medical team (89.1%) and kept the prescriptions updated (84.8%). The physicians reported resolutive appointments in 92.2% of cases, despite longer time to reach the patients and subsequent calls to complement missing information. Satisfaction and patient-provider relationship were maintained during the study, but the choice for virtual appointment for the next appointment fell from 78.7% to 34.8% after 6 months. Coronavirus disease 2019 (COVID-19) was confirmed in 13% of patients, mostly mild and moderate manifestations. Conclusion: Telemedicine is a tool for medical care in underserved populations, feasible even in low-income countries. This study suggests that it is difficult to sustain exclusive remote care for more than 6 months. The method could be adopted interchangeably with in-person consultations in acromegalic patients with stable disease.

Creating Solutions for Meeting the Challenges of Maintaining a Healthy Work Practice: Our Experience at a County Hospital

Creating Solutions for Meeting the Challenges of Maintaining a Healthy Work Practice: Our Experience at a County Hospital

Design and implementation of a cluster randomized trial measuring benefits of medical scribes in the VA

BackgroundMedical scribes are trained professionals who assist health care providers by administratively expediting patient encounters. Section 507 of the MISSION Act of 2018 mandated a 2-year study of medical scribes in VA Medical Centers (VAMC). This study began in 2020 in the emergency departments and specialty clinics of 12 randomly selected VAMCs across the country, in which 48 scribes are being deployed. MethodsWe are using a cluster randomized trial to assess the effects of medical scribes on productivity (visits and relative value units [RVUs]), wait times, and patient satisfaction in selected specialties within the VA that traditionally have high wait times. Scribes will be assigned to emergency departments and/or specialty clinics (cardiology, orthopedics) in VAMCs randomized into the intervention. Remaining sites that expressed interest but were not randomized to the intervention will be used as a comparison group. ResultsProcess measures from early implementation of the trial indicate that contracting may hold an advantage over direct hiring in terms of reaching staffing targets, although onboarding contractor scribes has taken somewhat longer (from job posting to start date). ConclusionsOur evaluation findings will provide insight into whether scribes can increase provider productivity and decrease wait times for high demand specialties in the VA without adversely affecting patient satisfaction. ImplicationsAs a learning health care system, this trial has great potential to increase our understanding of the potential effects of scribes while also informing a real policy problem in high wait times and provider administrative burdens.

564 Patient Charactarestics With Normal to Mild Apnea Hypopnea Index Undergoing Polysomnography to Diagnose Obstructive Sleep Apnea

Abstract Introduction Polysomnography (PSG) testing is expensive and not easily accessible. Waiting time for a routine PSG at the Alberta Children’s Hospital (ACH) can be up to a year. Majority of PSG studies performed are for diagnosis of obstructive sleep apnea (OSA). A previous quality improvement (QI) project conducted at the ACH showed that two-thirds of children who had undergone initial PSG testing had an apnea hypopnea index (AHI) in the normal or mild range. Given our limited resources, better characterization of patient referral characteristics and process factors as documented on the PSG requisition will inform our triage process, decrease wait time, improve resource allocation and information provided to referral sources. Methods Retrospective review of PSG’s performed for the initial diagnosis of OSA was completed between January 2018 and March 2020 at the ACH. Patient referral characteristics (age, sex, growth parameters, medical diagnosis, indication for PSG, previous airway surgery), process factors (source of referral, PSG referral and completion date, triage status) and AHI were recorded. Patients were divided into two groups (group A: normal and mild; group B: moderate and severe) based on AHI. Data obtained from the groupings were compared and analyzed descriptively. PSG triage to completion time was also calculated for each group. Results A total of 798 initial PSG studies were completed between January 2018 and March 2020. Of the PSG’s reviewed 64.8% were in group A and 35.2% were in group B. Common medical diagnoses in group A included ADHD, Asthma and Autism, whereas group B had T21 and Enuresis. History of previous airway surgery did not differ between groups. Conclusion Further clarification of the patient’s underlying medical diagnosis (referral characteristic) may help inform our triage process. The implication of previous airway surgery (process factor) on AHI severity is unclear at this point. More data is actively being collected to further interrogate these preliminary findings. Support (if any):

Pilot study: The effectiveness of physiotherapy-led screening for patients requiring an orthopedic intervention

LAY SUMMARY In Canada, patients can wait over a year to be seen by an orthopedic surgeon. To reduce wait times, physiotherapists have been employed in some practice areas to triage patients prior to being seen by an orthopedic surgeon. This study looked at different forms of triage by using physiotherapists to screen electronic medical records (EMR) to determine if patients needed orthopedic intervention or conservative management. To guide the physiotherapists, a screening tool was created. The study compared the recommendations of the physiotherapists with those of an orthopedic surgeon. The results showed that, most of the time, physiotherapists using the screening tool successfully identified whether a patient needed to see an orthopedic surgeon or could be treated with physiotherapy. This type of screening process may decrease wait times to see an orthopedic surgeon and improve access to physiotherapy or other treatments.