Delays In Patient Care Research Articles

S1222 Low Yield of Novel Coronavirus 2019 (COVID-19) Testing Prior to Endoscopic Procedures in a Community-Based Gastroenterology Practice

INTRODUCTION: The Novel Coronavirus 2019 (COVID-19) pandemic has limited endoscopic utilization causing significant health and economic losses. Accordingly, gastroenterology (GI) societies recommended COVID-19 testing to screen all patients undergoing endoscopic procedures which resulted in a relatively increased access to such interventions. Nonetheless, this approach can be limited by the cost and availability of testing. We evaluated the feasibility and yield of this approach in detecting patients with COVID-19 at our community-based GI practice which is located in an area with a low COVID-19 prevalence of <1%. METHODS: This is a clinical, non-interventional, observation-based quality initiative of patients scheduled for endoscopic procedures at our community-based GI practice from May 11th to June 4th, 2020. All patients underwent symptoms screening, followed by polymerase chain reaction (PCR)-based testing. Based on the testing result, a decision whether to proceed with endoscopic procedure or not was made. After the procedure, providers were followed closely to early detect any concerning symptoms. RESULTS: A total of 285 patients were scheduled for endoscopic procedures during that time period, 270 were tested for COVID-19. Table 1 details patient baseline characteristics. None of the patients had a positive test result, with only one individual appearing symptomatic but later testing negative. The remaining 15 patients did not undergo their scheduled endoscopic procedure as they did not undergo the required COVID-19 testing prior to their procedure (Figure 1). None of the providers developed COVID-19 related symptoms after the endoscopic procedures. CONCLUSION: Over a 1-month period, we observed a 0% positive test rate for COVID-19 at our GI practice. The results suggest that the current testing protocol may not be cost effective or add much to the safety of patients and providers in low prevalence areas. The most commonly used PCR test can have up to 48 hours turn-around time, which could potentially delay patient care and the overall efficiency of the practice. Therefore, preserving PCR testing to patients with high index of suspicion at GI practices with similar positive test rates as ours, may be a reasonable option in order to improve access to endoscopic procedures. Larger scale, multi-center studies are needed to corroborate these findings. In the interim, strict use of personal protective equipment during endoscopic procedures should continue to be strongly emphasized.Table 1.: Baseline Patient CharacteristicsFigure 1.: Patient Testing Results.

Reducing The Rate of Inappropriate Inpatient Transthoracic Echocardiograms Through an Educational Intervention

Introduction Transthoracic echocardiogram (TTE) is a popular imaging modality frequently ordered in the inpatient setting for diagnosis and management of cardiovascular diseases. However, TTEs are a limited resource, and inappropriate use contributes to unnecessary cost and delays in patient care. Our aim was to decrease the burden of inappropriate inpatient TTEs by 50% over 6 weeks through an educational intervention at an academic medical center. Methods We developed and implemented an educational intervention in January 2020 at a large tertiary care academic medical center by delivering lectures to Internal Medicine residents during daily conferences about the 2011 appropriate use criteria (AUC) for TTEs according to the American College of Cardiology. We chart reviewed all TTEs ordered for patients admitted to the general medicine service in the 6 weeks preceding and 6 weeks following our educational intervention. TTEs ordered by the cardiology team or CCU were excluded. We analyzed the proportion of appropriate TTEs ordered based on the AUC and total time to completion over these two periods. Results The median proportion of appropriately ordered TTEs over the duration of the study was 88.3% (Figure 1). In the pre-intervention period, the median proportion of appropriately ordered TTEs was 95.5% with an average time to completion of 23.6 hours. In the post-intervention period, the median proportion of appropriately ordered TTEs was 85.7% with an average time to completion of 29.2 hours. Conclusion The TTEs ordered by internal medicine residents are largely appropriate even before being educated on AUC. The proportion of appropriate TTEs decreased slightly in the post-intervention period, which may be related to normal variation or a by-product of the continual rotation of trainees and need for a longer study duration. Future efforts to achieve a higher rate of appropriately ordered TTEs will include providing this education on AUC to other non-medicine services and implementing a TTE order set containing the AUC.

Prolonged time to extubation after general anaesthesia is associated with early escalation of care: A retrospective observational study.

Prolonged time to extubation after general anaesthesia has been defined as a time from the end of surgery to airway extubation of at least 15 min. This occurrence can result in ineffective utilisation of operating rooms and delays in patient care. It is unknown if unanticipated delayed extubation is associated with escalation of care. To assess the frequency of 'prolonged extubation' after general anaesthesia and its association with 'escalation of care before discharge from the postanaesthesia care unit', defined as administration of reversal agents for opioids and benzodiazepines, airway re-intubation and need for ventilatory support. In addition, we tried to identify independent factors associated with 'prolonged extubation'. Single-centre retrospective study of cases performed from 1 January 2010 to 31 December 2014. A large US tertiary academic medical centre. Adult general anaesthesia cases excluding cardiothoracic, otolaryngology and neurosurgery procedures, classified as: Group 1 - regular extubation (≤15 min); Group 2 - prolonged extubation (≥16 and ≤60 min); Group 3 - very prolonged extubation (≥61 min). First, cases with prolonged time to extubation; second, instances of escalation of care per extubation group; third, independent factors associated with prolonged time to extubation. A total of 86 123 cases were analysed. Prolonged extubation occurred in 8138 cases (9.5%) and very prolonged extubation in 357 cases (0.4%). In Groups 1, 2 and 3 respectively, naloxone was used in 0.4, 4.1 and 3.9% of cases, flumazenil in 0.03, 0.6 and 2% and respiratory support in 0.2, 0.7 and 2%, and immediate re-intubation occurred in 0.1, 0.3 and 2.8% of cases. Several patient-related, anaesthesia-related and procedure-related factors were independently associated with prolonged time to extubation. Prolonged time to extubation occurred in nearly 10% of cases and was associated with an increased incidence of escalation of care. Many independent factors associated with 'prolonged extubation' were nonmodifiable by anaesthetic management.

Registered Nurse Strain Detection Using Ambient Data: An Exploratory Study of Underutilized Operational Data Streams in the Hospital Workplace.

Registered nurses (RNs) regularly adapt their work to ever-changing situations but routine adaptation transforms into RN strain when service demand exceeds staff capacity and patients are at risk of missed or delayed care. Dynamic monitoring of RN strain could identify when intervention is needed, but comprehensive views of RN work demands are not readily available. Electronic care delivery tools such as nurse call systems produce ambient data that illuminate workplace activity, but little is known about the ability of these data to predict RN strain. The purpose of this study was to assess the utility of ambient workplace data, defined as time-stamped transaction records and log file data produced by non-electronic health record care delivery tools (e.g., nurse call systems, communication devices), as an information channel for automated sensing of RN strain. In this exploratory retrospective study, ambient data for a 1-year time period were exported from electronic nurse call, medication dispensing, time and attendance, and staff communication systems. Feature sets were derived from these data for supervised machine learning models that classified work shifts by unplanned overtime. Models for three timeframes -8, 10, and 12 hours-were created to assess each model's ability to predict unplanned overtime at various points across the work shift. Classification accuracy ranged from 57 to 64% across three analysis timeframes. Accuracy was lowest at 10 hours and highest at shift end. Features with the highest importance include minutes spent using a communication device and percent of medications delivered via a syringe. Ambient data streams can serve as information channels that contain signals related to unplanned overtime as a proxy indicator of RN strain as early as 8 hours into a work shift. This study represents an initial step toward enhanced detection of RN strain and proactive prevention of missed or delayed patient care.

Mission Control: The Development and Centralization of an Integrated Communication Center to Facilitate Intra-Facility and Inter-Facility Patient Flow

Background: Patient flow is an inherently challenging process exacerbated by the demands of a busy pediatric academic center and seasonal illnesses. When patient flow is not optimized, it leads to delays in patient care, patient and staff dissatisfaction, and potential financial loss. There are multiple stakeholders involved in this logistically complex process. As our institution grew and expanded to multiple campuses, the need for a multidisciplinary, centralized hub to oversee and coordinate real-time patient movement focusing on inbound critical care transports became evident. Methods: Our institution proposed a centralized, physical space to …

Clinical efficacy and safety of palliative esophageal stenting without fluoroscopy: a systematic review and meta-analysis.

Background and study aims Despite advances in curative treatments for esophageal cancer, many patients often present with advanced disease. Dysphagia resulting in significant weight loss and malnutrition leads to poor quality of life. Palliative esophageal stenting with self-expanding metal stents (SEMS) helps alleviate symptoms and prolongs survival. However, access to fluoroscopy may be limited at certain centers causing delay in patient care. Methods We searched multiple databases from inception to November 2019 to identify studies evaluating the efficacy and safety of endoscopic palliative esophageal stenting and selected only those studies where fluoroscopic guidance was not used. Our primary aim was to calculate the overall technical as well as clinical success. Using meta-regression analysis, we also evaluated the effect of tumor location and obstruction length on overall technical and clinical success. Results A total of 1778 patients from 17 studies were analyzed. A total of 2036 stents were placed without the aid of fluoroscopy. The pooled rate of technical success was 94.7 % (CI 89.9–97.3, PI 55–99; I 2 = 85) and clinical success was 82.1 % (CI 67.1–91.2, PI 24–99; I 2 = 87). Based on meta-regression analysis both the length of obstruction and tumor location did not have any statistically significant effect on technical and clinical success. The pooled rate of adverse events was 4.1 % (CI 2.4–7.2; I 2 = 72) for stent migration, 8.1 % (CI 4.1–15.4; I 2 = 89) for tumor overgrowth and 1.2 % (CI 0.7–2; I 2 = 0) for perforation. The most frequent clinical adverse event was retro-sternal chest pain. Conclusion Palliative esophageal stenting without fluoroscopy using SEMS is both safe and effective in patients with advanced esophageal cancer.

LO37: Reducing hemolysis of coagulation blood samples in the emergency department

Background: Hemolysis of blood samples is the leading cause of specimen rejection from hospital laboratories. It contributes to delays in patient care and disposition decisions. Coagulation tests (prothrombin time/international normalized ratio [PT/INR] and activated partial thromboplastin time [aPTT]) are especially problematic for hemolysis in our academic hospital, with at least one sample rejected daily from the emergency department (ED). Aim Statement: We aimed to decrease the monthly rate of hemolyzed coagulation blood samples sent from the ED from a rate of 2.9% (53/1,857) to the best practice benchmark of less than 2% by September 1st, 2019. Measures &amp; Design: Our outcome measure was the rate of hemolyzed coagulation blood samples. Our process measure was the rate of coagulation blood tests sent per 100 ED visits. Our balancing measure was the number of incident reports by clinicians when expected coagulation testing did not occur. We used monthly data for our Statistical Process Control (SPC) charts, as well as Chi square and Mann-Whitney U tests for our before-and-after evaluation. Using the Model for Improvement to develop our project's framework, we used direct observation, broad stakeholder engagement, and process mapping to identify root causes. We enlisted nursing champions to develop our Plan-Do-Study-Act (PDSA) cycles/interventions: 1) educating nurses on hemolysis and coagulation testing; 2) redesigning the peripheral intravenous and blood work supply carts to encourage best practice; and 3) removing PT/INR and aPTT from automatic inclusion in our electronic chest pain bloodwork panel. Evaluation/Results: The average rate of hemolysis remained unchanged from baseline (2.9%, p = 0.83). The average rate of coagulation testing sent per 100 ED visits decreased from 41.5 to 28.8 (absolute decrease 12.7 per 100, p &lt; 0.05), avoiding $4,277 in monthly laboratory costs. The SPC chart of our process measure showed special cause variation with greater than eight points below the centerline. Discussion/Impact: Our project reduced coagulation testing, without changing hemolysis rates. Buy-in from frontline nurses was integral to the project's early success, prior to implementing our electronic approach – a solution ranked higher on the hierarchy of intervention effectiveness – to help sustainability. This resource stewardship project will now be spread to a nearby institution by utilizing similar approaches.

Managing difficult catheterisation in nurse‐led catheterisation services: Does guidewire‐assisted urethral catheterisation make a difference?

AbstractThe use of guidewires is well established in medical practice, but relatively new in nurse‐led catheterisation services (NCS). We investigate the incidence of difficult urethral catheterisation and whether guidewire‐assisted catheterisation reduces disrupted patient care. A retrospective Audit (September 2016‐August 2017) recorded incidence and management of difficult catheterisation in two NCS. In NCS‐A, nurses were familiar with improvised guidewire‐assisted catheterisation, whereas in NCS‐B nurses were not enabled and had to refer patients to urologists when they encountered problems. From September 2017 to August 2018, a National Institute for Health and Care Excellence (NICE)‐approved urethral catheterisation device with integrated guidewire (Urethrotech UCD) was used in NCS‐B for difficult urethral catheterisation. User and patient satisfaction was evaluated prospectively. Of 540 men attending NCS‐A for trial without catheter (TWOC), 31% (169/540) were recatheterized, of whom 4%(6/169) required a guidewire‐catheterisation technique to manage difficult catheterisation without problems. This was also done in 45 of 146 men attending for long‐term catheter change with known history of difficult catheter change. Of 1002 men attending NCS‐B for TWOC, 23% (226/1002) were recatheterized. This was difficult in 25% (57/226), of which 40% (23/57) suffered complications with bleeding from repeated catheterisation attempts and 10 men had to be admitted for specialist interventions to manage retention and catheterisation‐associated urethral injury. During the prospective audit, 945 men attended the TWOC‐clinic of NCS‐B. In 11% (13/120), the UCD was used for failed Foley‐catheterisation without complications. Patients and users were very satisfied because the difficult recatheterisation episode was managed successfully without patient harm and care delay. Difficult urethral catheterisation is a frequent occurrence in NCS with significant risk of urethral trauma. Catheterisation‐associated urethral injury can be prevented with guidewire‐assisted urethral catheterisation techniques. The NICE‐approved UCD with integrated guidewire was easy to use with high user and patient satisfaction avoiding patient care delay and is supporting nurses to manage difficult urethral catheterisation safely making efficient use of specialist resources.

Capsule Endoscopy Transit Time to Duodenum: Relation to Patient Demographics.

BackgroundAnesthesia guidelines recommend fasting for at least two hours to minimize aspiration risk related to endoscopic procedures, and the American Society for Gastrointestinal Endoscopy (ASGE) states that the final oral preparation liquid can be administered three to eight hours before the procedure. We have observed the cancellation of endoscopy procedures if liquids were consumed within four, six, or eight hours of the start time. Objectively, documenting gastric transit time via a review of pill endoscopy data could address clinician concerns, prevent delays in patient care, and improve the rate at which our clinicians practice within national guidelines. The objective was to utilize capsule endoscopy data from our center to report the relationship between patient factors that could affect gastric transit time (GTT) and small bowel transit time (SBTT) such as chronic kidney disease (CKD), diabetes mellitus (DM), nutritional status, and obesity.MethodsThis retrospective review obtained data on adult pill endoscopy (PillCam™ SB 3) (Medtronic, Minneapolis MN) studies on in- and outpatients. Past medical history and laboratory data were abstracted from electronic medical records. Mean GTT and SBTT are reported in minutes + standard deviation (SD) and times were compared accounting for conditions that could prolong transit, such as diabetes mellitus or chronic kidney disease (CKD).ResultsOne hundred and sixty-three records reviewed. Four patients were excluded as the pill did not pass out of the stomach. The mean age was 66 years, 57% were female, and 26% were evaluated for gastrointestinal (GI) bleeding. The mean GTT for all patients (n = 159) was 35 + 49 with a median of 19 minutes. There were no statistically significant differences in GTT between the following subgroups: CKD0 (n = 100) 40 + 58 versus CKD5 (n = 11) 35 + 39, albumin > 3.0 (n = 123) 37 + 53 versus albumin < 3.0 (n = 36) 27 + 30, diabetes mellitus (DM) (n = 40) 51 + 71 vs. non-DM (n = 119) 42 + 79, body mass index (BMI) > 30, or aspirin use. The SBTT results in all patients (n = 124) was 238 + 88 minutes. Similarly, there was no relation between SBTT and albumin, any CKD, CKD0 versus CKD5, DM status, or BMI. The patients with the capsule stuck in the stomach did not have any other clinical history to explain this occurrence.ConclusionsThis analysis of objective data regarding pill endoscopy found that the mean GTT was 44 minutes, and it was < 60 minutes for 85% of the cohort. Patient factors were not associated with longer transit times, and this is the first report to document PillCam times in relation to CKD. These data support recommendations that endoscopic procedures, in accordance with anesthesia and ASGE guidelines, can be safely conducted in the majority of patients within 60 minutes of ingesting liquids.

Ten tips for foundation doctors when making inpatient referrals to surgical specialties

Making referrals to another specialty is an underemphasised skill in the undergraduate medical curriculum. As a result, many new foundation doctors find themselves ill-equipped to make effective referrals to other...

Delay in head and neck cancer care during the COVID-19 pandemic and its impact on health outcomes.

The coronavirus disease 2019 (COVID-19) outbreak has created unprecedent challenges for healthcare systems worldwide. Oncology services have been reorganized to decrease the risk of nosocomial acquisition of SARS-CoV-2, but changes in treatment pathways and follow-up cancer care can result in patients receiving suboptimal or delayed care. Herein, we describe a cross-sectional nested cohort study conducted to evaluate delays in care for patients with head and neck cancer (HNC) in post-treatment follow-up or palliative care during the COVID-19 pandemic in Northeast Brazil and its impact on health outcomes. Information was extracted from medical records and supplemented by telephone interviews. We compared the following health outcomes: self-perception of anxiety or sadness, fear of COVID-19 infection, cancer-related complications during social isolation, self-medication, diagnosis of COVID-19, and death between patients with and without delayed cancer care. The Mann-Whitney U test was used to compare distributions of continuous variables and the Fisher exact test was used for categorical variables. Thirty-one HNC patients were included in the study, and no case of confirmed SARS-CoV-2 was found. Delayed cancer care due to restriction in health services was reported in 58.1% of cases, and there was no report of telemedicine use during the COVID-19 outbreak. Cancer-related complications during the COVID-19 pandemic were described for most patients (67.7%) and included pain or discomfort, swelling, and dyspnea. Eight (25.8%) patients reported use of prescribed morphine or codeine to manage pain and six (19.4%) patients reported self-medication with over-the-counter (OTC) non-steroidal anti-inflammatory drugs (NSAIDs). We found an association between delayed HNC care and the use of self-medication (p = 0.028). This study indicated that patients with delayed HNC care during the COVID-19 outbreak are more likely to use self-medication with NSAIDs for pain management. Better strategies to follow HNC patients in socioeconomically disadvantaged communities need to be discussed and implemented.

775: The predictive value of tachycardia thresholds to identify maternal morbidity

Tachycardia may be a marker of clinical deterioration prior to critical illness, though normal pregnancy physiology may also result in tachycardia. While tachycardia is a parameter included in all maternal early warning systems, it is unclear what level of tachycardia best predicts maternal morbidity. This study examines the association of tachycardia with maternal morbidity. This retrospective cohort study analyzed all pregnant patients ≥18 years old at any gestational age admitted to the obstetric service of a large academic medical center in 2018. Vital signs and clinical data were extracted from the electronic medical record. Tachycardia was characterized according to 5 heartrate (HR) thresholds: >110, >120, >130, >140, and >150 beats per minute. The primary outcome was maternal morbidity (Table 1) defined according to clinical criteria and diagnosis codes. Test characteristics of each tachycardia threshold were compared and plotted on a receiver-operator characteristic (ROC) curve. Of 14,597 obstetric admissions included in the study, 2,451 experienced morbidity (16.8%). 62.3% of patients with morbidity had HR >110, while only 9.8% had HR >150. 37.7% of patients with morbidity did not have HR >110. The false positive rate was 43.8% for HR >110 and 5.6% for HR >110 (Table 1). Specificity was highest for HR >140 (91.0%) and >150 (94.4%) and positive and negative predictive values were similar for all thresholds, ranging from 22.3 to 26.2% and 88.1 to 83.8%, respectively. The ROC curve demonstrated an area-under-the-curve (AUC) of 0.74 (Figure 1). The predictive value of tachycardia for morbidity in obstetric patients is modest. Most patients with tachycardia do not experience increased morbidity and fewer than half of patients with increased morbidity experience HR >120 bpm. Clinical response may need to incorporate other criteria, such as bedside nursing assessment and subjective complaints, to avoid signal saturation from benign tachycardia and to prevent delays in care for patients without abnormal heart rate.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Abstract 462: Medical Emergency Team Replaces Code Blue Activations at Pediatric Hospital

Introduction: In free-standing pediatric hospitals, the Code Blue team may be activated for events in adults to provide triage, resuscitation, medical screening exams, EMTALA documentation and disposition decisions. However, activation of the Code Blue team can require significant time and critical care resources and may delay patient care if the activation is external to the building. Hypothesis: Development of a small triage team focused on specific adult triage algorithms will provide a safe, effective and efficient alternative to Code Blue team response. Methods: 407 bed tertiary pediatric hospital, within metropolitan area. Collaborative multi-disciplinary QI process to design and simulate the roles, workflow and documentation of the Medical Emergency Team (MET). Education and communication to hospital-wide staff on MET, as well as MET responders completion of Advanced Cardiac Life Support course. Collaboration with local EMS leadership to coordinate transfer of patient was also undertaken. Results: MET roles were developed and two configurations of the MET team were implemented July 2018: one inside the footprint of the building and anther outside the footprint of the building, including the hospital grounds. The teams consisted of a mid-level provider, charge nurse, two security officers and a shift administrator: inside team relied on ICU provider and charge nurse, while outside team led by Emergency Medicine provider and charge nurse. Each team had a backpack with supplies, and transport gurney. Since inception, 199 activations occurred, 191 inside and 8 outside the facility. The activations included 45 staff or volunteers, 84 adult visitors, 75 pediatric visitors. Outcome for the activations: 57 transported to the hospital ED, 47 transported to another facility, 21 refused treatment and 68 had resolution of concerns. EMTALA documentation was complete in 112/137 (82%). Conclusions: Pediatric hospitals have substantial adult populations, where medical emergencies that arise rely on Code Blue in medical emergencies for simplicity. Development of a response team for nonpatients allows specific training, triage, and processes to improve care and reduce drain on ICU resources.

Directly Observed Care: An Innovative Oncology Care Model in Belize

PURPOSE Patients with cancer in low- and middle-income countries face complex socioeconomic barriers within health systems that can lead to poor oncologic outcomes. Patient navigation has been shown to reduce disparities in oncologic outcomes in the United States. Belize, a middle-income country in Central America, has recently launched its first-ever public medical oncology program. Here, we report on the development of Directly Observed Care (DOC), a pilot patient navigation care model for patients with cancer in Belize, inspired from directly observed treatment for tuberculosis. METHODS DOC will be a patient-centered program, where a nurse trained in patient navigation will assume responsibility for proactively identifying barriers that Belizean patients with cancer face in access to care and working to remove them. This process will include patient education on cancer and its treatment, identification of financial barriers to care and potential funding sources, assistance with care logistics such as transportation and childcare, and referral to psychosocial support services for patients who need them. DOC will rely on an electronic patient-tracking platform, which will allow real-time tracking of all oncology patients and identify patients who miss or delay treatments. This will allow timely intervention and continuous quality monitoring of the program. In addition to patient navigation, DOC will seek to reduce delays in patient care by liaising with pathology and radiology services. RESULTS The program is in its development and pilot phase. So far, approximately 100 patients have been seen for consultation. We intend to capture epidemiologic data about cancer in Belize, as well as real-time data about the progression of patients through their treatment course. We aim to identify critical delays to patients’ care and design interventions to address them. CONCLUSION We believe that the DOC program will be particularly beneficial for the oncology patient population in Belize, because this population has a high burden of socioeconomic barriers to care and is largely unfamiliar with the complexity of oncologic care. We hypothesize that DOC can improve treatment appropriateness and timeliness and, thereby, patient outcomes in Belize.

Collaboration with commercial payor to eliminate prior authorization.

9 Background: For commercial insurance plans, there is often a requirement to obtain prior-authorization for specific services. Prior-authorization though intended to ensure medical necessity, can cause significant delays in patient care and create an unnecessary administrative burden. It often leads to undue anxiety in patients, dissatisfaction among providers and substantial waste in the system. To increase our efficiency and improve patient and provider experience, we partnered with one of our region’s largest commercial payors to eliminate prior-authorization. Methods: A Lean Six-sigma DMAIC approach was adopted: Define- created a process map. Measure- calculated baseline for prior-authorization denials. Analyze- conducted retrospective analysis to identify areas to improve. Improve- conducted provider training for appropriate imaging guidelines. Control- established internal auditing to check provider compliance. Results: At SCCA, we found that 94.8% of prior-authorizations were approved instantly or after providing more documentation, thus prior-authorization did not add value. Moreover, 2.15% were approved after peer-to-peer review that involves significant administrative burden and delay in care. Only 3% prior-authorizations did not meet medical necessity criteria, major reasons being- PET/CT and CT CAP ordered in combination, or PET/CT ordered without clear justification. 2.46% prior-authorizations led to a patient receiving a letter of denial. SCCA and the payor agreed to eliminate prior-authorizations for all imaging (except PET and PET/CT). This required all ordering providers to attest to completion of training on the NCCN Imaging Appropriate Use Criteria. In addition, a quarterly internal audit was put in place to check provider compliance to NCCN guidelines for ordering Imaging tests. SCCA achieved a 100% provider training completion rate and 100% provider compliance to NCCN guidelines in the first two internal audits. Conclusions: A strong partnership and shared vision with a payor enabled us to eliminate wasteful prior-authorizations. Our high training completion rate and compliance rate implies strong support from our providers and leadership to provide value-based care to our patients.

Diagnostic Management Team: Platelet Refractory Algorithm and Consult

Abstract Platelet refractoriness occurs when a patient fails to achieve appropriate platelet count increment following platelet (plt) transfusion. Approximately 30% to 40% of cases are due to human leukocyte antigen (HLA) alloantibodies and 2% to 10% are due to human platelet antigen (HPA) alloantibodies, which can be detected by various assays. The results of these tests are then used to guide selection of appropriate units, such as crossmatch-compatible (XM) and HLA-matched (HLAm) plts. Given the various steps and tests involved in diagnosing and managing plt refractoriness, clinicians may order unnecessary tests resulting in delays in patient care. In April 2018, our institution formed a diagnostic management team (DMT) to establish an algorithmic approach to testing, diagnosing, and transfusing plt refractory patients. We performed a retrospective review of clinician requests for XM or HLAm plts over a 9-month period prior to the launch of the DMT and compared that to requests placed during the initial 9-month period following the launch of the DMT. We collected the date transfusion medicine (TM) service was notified and the time to complete the following: 1-hour corrected count increment (CCI), ELISA indirect antibody screen, HLA flow cytometry PRA screen, HLA single antigen bead (SAB), and obtain the first XM or HLAm plt unit for the patient. There were 12 and 20 patients evaluated for plt refractoriness pre- and post-DMT, respectively. The median time to complete the ELISA indirect antibody screen was 2 days pre- and post-DMT, respectively. Eight percent of patients never had an ELISA screen performed pre-DMT. All patients meeting plt refractory criteria had ELISA screens performed post-DMT. Median time to complete HLA testing decreased from 4 days to 2 days and all patients who had positive FlowPRAs had subsequent SABs performed post-DMT compared to only 40% of patients pre-DMT. The median times to obtain the first XM unit were 6 and 5 days and the first HLAm unit was 5 and 6 days pre- and post-DMT, respectively. One patient had a CCI above 7,500 and four patients had negative screening ELISA and FlowPRA tests after the launch of the DMT. No further testing was performed and they continued to receive ABO-compatible (ABOc) plt units. Since the launch of the DMT, there is improved consistency regarding what tests are performed and standardization of the sequence in which the appropriate tests are ordered. We have reduced unnecessary testing by identifying patients with nonimmune-mediated etiologies of plt refractoriness. Divergence from the algorithm is the main issue encountered during the initial 9-month period following implementation of the DMT. This divergence stemmed from lack of consistent education about plt refractoriness and the DMT. We believe better adherence to the algorithm will lead to decreased product acquisition time and further improve efficiency.

A study on prescribing errors in in-patients of a corporate tertiary care hospital in North India

Background: Prescribing errors are a subset of medication errors which have a potential for grave harm to the patient. Identification and acknowledgement of such errors can ameliorate much of this danger. Studies of prescribing errors are sparse in India. Such studies, whatever have been conducted, mainly focus on the out-patients or the patients on discharge. Hence, this study was undertaken to study the prescribing errors in prescriptions generated for patients admitted in wards of a corporate hospital in North India.Methods: The prescriptions for in-patients admitted in wards were analyzed for different types of prescribing errors in individual drug orders and prescription as a whole.Results: The prescribing error rate was found to be 3.3% in this study. Of all errors, errors leading to delays in patient care (i.e. Errors of prescription writing) (54.54%) and erroneous copying of the prescription to the drug chart by junior/ resident doctors (Transcription errors) (31.31%) were found to be the major causes of prescribing errors in this study. Of the former category, prescribing a wrong strength (24.24%) and illegible drug orders (12.12%) were the most numerous error subtypes. Errors leading to sub-optimal patient care (i.e. Errors of decision making) were least identified of which Therapeutic duplication (12.12%) was the most common subtype.Conclusions: The error rate found in this study is comparable to the data available from developed countries. However, there are significant differences in the occurrences of error subtypes found in this study as compared to the studies of the west.

Emergency department and hospital crowding: causes, consequences, and cures

Overcrowding with associated delays in patient care is a problem faced by emergency departments (EDs) worldwide. ED overcrowding can be the result of poor ED department design and prolonged throughput due to staffing, ancillary service performance, and flow processes. As such, the problem may be addressed by process improvements within the ED. A broad body of literature demonstrates that ED overcrowding can be a function of hospital capacity rather than an ED specific issue. Lack of institutional capacity leads to boarding in the ED with resultant ED crowding. This is a problem not solvable by the ED and must be addressed as an institution-wide problem. This paper discusses the causes of ED overcrowding, provides a brief overview of the drastic consequences, and discusses possible cures that have been successfully implemented.

Appropriate utilisation of cardiac telemetry monitoring: a quality improvement project

For hospitals located in the United States, appropriate use of cardiac telemetry monitoring can be achieved resulting in cost savings to healthcare systems. Our institution has a limited number of...

03:27 PM Abstract No. 36 Process map for interventional radiology at a large tertiary children’s hospital: understanding the workflow and identifying areas for improvement

Process mapping can be used to identify healthcare waste and inefficiencies. We chose to observe pediatric interventional radiology (IR) processes for inpatients undergoing procedures with general anesthesia to create a process map and identify delays in patient care. A fourth-year medical student was assigned to observe the process of coordinating inpatient IR procedures (2 IR rooms) at a tertiary care children’s hospital for 2 weeks. The medical student began following a single patient at initiation of transfer from the inpatient floor until the patient exited the IR suite. Predetermined variables were recorded for each patient observation. Post anesthesia Care Unit (PACU) nurses were tasked with recording discharge times from the PACU. During this process, team member duties were recorded chronologically for future integration into a process map. Overall, 19 inpatient procedures were completely tracked. We found notable delays in patient transport times (mean 38 mins, range 22–68 mins), pre-procedure evaluation (mean 22 mins, range 13–31 mins), and preoperative/PACU space availability. Estimated time for scheduling the procedure in the IR suite (mean 68.5 mins, range 60–120 mins) was shown to be an underestimate when compared to the measured procedure duration (mean 77 mins, range 31–181 mins). With all members of the IR team, including IR nurses and radiology technologists, a process map was created to map the roles of each team member. Results from the observation were discussed at a team meeting to receive input and feedback from all members of the IR team. We have implemented changes in our workflow to address these issues. Patient transport is now solicited at earlier times to reflect appropriate transport lags. We found our team to be efficient in preparing the patient for the procedure with most of our delays being attributable to PACU bed availability. By analyzing our processes, inefficiencies in workflow and delays in coordination of patient care were identified. Implementation of targeted changes at our institution should lead to improved efficiency. Process mapping can be used to help other IR departments in identifying their inefficiencies.