Delays In Patient Care Research Articles

Hemolyzed Laboratory Specimens in the Emergency Department: An Underappreciated, but Frequent Problem

IntroductionHemolysis of blood samples from emergency department (ED) patients leads to delays in treatment and disposition. The aim of this study is to determine the frequency of hemolysis and variables predictive of hemolysis. MethodsThis observational cohort study was conducted among three institutions: academic tertiary care center and two suburban community EDs, with an annual census of over 270,000 ED visits. Data were obtained from the electronic health record. Adults requiring laboratory analysis with at least one peripheral intravenous catheter (PIVC) inserted within the ED were eligible. Primary outcome was hemolysis of lab samples and secondary outcomes included variables related to PIVC failure. ResultsBetween January 8, 2021 and May 9, 2022, 141,609 patient encounters met inclusion criteria. The average age was 55.5 and 57.5% of patients were female. Hemolysis occurred in 24,359 (17.2%) samples. In a multivariate analysis, when compared to 20-gauge catheters, smaller 22-gauge catheters had an increased odds of hemolysis (OR 1.78, 95% confidence interval (CI) 1.65-1.91; P < .001), while larger 18-gauge catheters had a lower odds of hemolysis (OR 0.94; 95% CI 0.90-0.98; P = .0046). Additionally, when compared to antecubital placement, hand/wrist placement demonstrated increased odds of hemolysis (OR 2.06; 95% CI 1.97-2.15; P < .001). Finally, hemolysis was associated with a higher rate of PIVC failure (OR 1.06; 95%CI 1.00-1.13; P = 0.043). DiscussionThis large observational analysis demonstrates that lab hemolysis of is a frequent occurrence among ED patients. Given the added risk of hemolysis with certain placement variables, clinicians should consider catheter gauge/placement location to avoid hemolysis that may result in patient care delays and prolonged hospital stays.

P30 Declining staff numbers and increasing workload: is there a solution?

Abstract Within the UK, there is a rapidly rising incidence of malignancies, including cutaneous cancers. Over 1 million new patients are referred to dermatology each year and a large proportion require a diagnostic or therapeutic biopsy. Dermatologists often rely on histopathology to confirm or diagnose cancers, determine margins and perform specialist testing. The increasing rates of cancers are adding significantly to the histopathology workload. According to the Royal College of Pathologists (RCPath), only 3% of departments report having adequate staff to meet clinical demand. There are a significant number of unfilled training posts and a concurrent retirement crisis, with 25% of all pathologists over 55 years old. It can take up to 15 years to train consultants, with the more experienced able to handle greater workloads. The lack of pathologists, with widespread vacancies, has a significant impact. The resulting costs to the health service of employing locums and outsourcing work have been estimated to be £27 million annually. For patients, the costs of these shortages mean delays in diagnosis and treatment. A RCPath key performance indicator advises that 80% of cases should be reported within 7–10 calendar days. Across dermatology departments, there is wide reported variation in reporting times from 1 to 28 weeks. In 2019, the longest wait, on average, was 5.8 weeks. We surveyed 60 histopathology consultants across different National Health Service trusts in England to determine the reasons behind these delays. The survey response rate was 45%. The results showed that 78% of departments have unfilled posts, 83% have employed locum staff or outsourced reporting of skin biopsies in the last 5 years and only 20% are able to meet the RCPath guidance. Additionally, almost one-quarter reported that they have had complaints or serious incidences related to delayed dermatopathology reporting. Survey comments revealed many other areas of potential diagnostic delay from sample labelling and prioritizing to prolonged laboratory processing times, unclear pathways to expedite samples and the lack of histopathology secretaries. This survey highlights the increasing workforce demands and emphasizes the need for innovative changes to avoid delays in patient care. Possible solutions to address increased workload in an understaffed environment include adequate secretarial support, increasing pathology pathway navigators who prioritize urgent cases, improving information technology services, digital slide reporting and developing artificial intelligence to screen samples. Increasing dermatopathology training and exposure to histopathology at a junior level is mandatory. Raising these issues and making them a key investment priority for the government is imperative.

DP02 (P30) Declining staff numbers and increasing workload: is there a solution?

Abstract Within the UK, there is a rapidly rising incidence of malignancies, including cutaneous cancers. Over 1 million new patients are referred to dermatology each year, and a large proportion requires a diagnostic or therapeutic biopsy. Dermatologists often rely on histopathology to confirm or diagnose cancers, determine margins and perform specialist testing. The increasing rates of cancers are adding significantly to the histopathology workload. According to the Royal College of Pathologists (RCPath), only 3% of departments report having adequate staff to meet clinical demand. There are a significant number of unfilled training posts and a concurrent retirement crisis, with 25% of all pathologists over 55 years old. It can take up to 15 years to train consultants, with the more experienced able to handle greater workloads. The lack of pathologists, with widespread vacancies, has a significant impact. The resulting costs to the health service of employing locums and outsourcing work has been estimated to be £27 million annually. For patients, the costs of these shortages mean delays in diagnosis and treatment. A RCPath key performance indicator advises that 80% of cases should be reported within 7–10 calendar days. Across dermatology departments, there is a wide reported variation in reporting times from 1 to 28 weeks. In 2019, the longest wait, on average, was 5.8 weeks. We surveyed 60 histopathology consultants across different National Health Service trusts in England to determine the reasons behind these delays. The survey response rate was 45%. The results showed that 78% of departments have unfilled posts, 83% have employed locum staff or outsourced reporting of skin biopsies in the last 5 years and only 20% are able to meet the RCPath guidance. Additionally, almost one-quarter reported that they have had complaints or serious incidences related to delayed dermatopathology reporting. Survey comments revealed many other areas of potential diagnostic delay from sample labelling and prioritizing to prolonged laboratory processing times, unclear pathways to expedite samples and lack of histopathology secretaries. This survey highlights the increasing workforce demands and emphasizes the need for innovative changes to avoid delays in patient care. Possible solutions to address increased workload in an understaffed environment include adequate secretarial support, increasing pathology pathway navigators who prioritize urgent cases, improving information technology services, digital slide reporting and developing artificial intelligence to screen samples. Increasing dermatopathology training and exposure to histopathology at a junior level is mandatory. Raising these issues and making them a key investment priority for the government is imperative.

Virtual nutrition services in oncology.

e13504 Background: In 2016, the National Academy of Sciences, Engineering and Medicine convened a workshop to examine challenges patients experience accessing specialized nutrition care in outpatient cancer treatment settings. Inadequate Registered Dietitian Nutritionist (RDN) staffing and reimbursement were identified as barriers to timely care. Staffing challenges at our three destination community cancer centers led to a backlogged queue of nutrition consults resulting in a ≥ 4-week wait time for an appointment. A quality improvement project to address delays in care for patients at risk for malnutrition, resulted in implementation of a hybrid model utilizing remote RDNs to provide virtual Medical Nutrition Therapy (MNT) to supplement onsite RDNs. Methods: After approved in June 2022, two remote RDNs were hired to provide virtual patient care. Nationwide recruitment allowed for hiring rare talent. A project team was created to assure we followed all regulatory guidelines related to licensing and billing. RDNs were individually licensed in 14 states to cover where ≥ 70% of our patients reside. System-wide criteria and licensure alerts for appointments were established between scheduling and nutrition leaders. The first patients were seen virtually on October 14, 2022, with units of service (uos) logged in 15-minute increments. Results: Appointments were tracked from October 14, 2022, through February 3, 2023. 69.2% of 302 scheduled appointments were successfully delivered virtually via telehealth platform with a mean of 1.7 uos. The main reasons for nonuse of the platform were no shows (52.7%) and the need to convert to a phone call (32.3%). The mean uos was significantly higher in new patients compared to returning patients (2.23 versus 1.53; p&lt;0.001). Conclusions: A hybrid model of onsite and virtual care RDNs has potential to improve access to nutrition care. New patient appointments averaged &gt; 30 minutes, and follow-ups averaged &lt; 30 minutes. This may help inform future scheduling of virtual MNT appointments. This model may allow for recruitment from a wider pool of RDNs. It may also help avoid delays in care for patients at risk for malnutrition and gaps in their cancer treatment. [Table: see text]

Histological Characteristics and Management of Hepatitis on Immune Checkpoint Inhibitors: A Retrospective Descriptive Study.

the side effects of immune checkpoint inhibitors (ICI) pose a problem for the clinical management of cancer patients. There is a lack of knowledge of the value of liver biopsy in patients with ICI-related drug-induced liver injury (ICI-DILI). The aim of this study was to explore the impact of liver biopsy on clinical management and response to corticosteroids, according to histological findings. We conducted a retrospective, single-center study to evaluate the biochemical, histological and clinical data of 35 patients with ICI-DILI between 2015 and 2021 in a university hospital in France. Of the 35 patients with ICI-DILI (median [interquartile range] age 62 [48-73] years, 40% males) studied, 20 underwent a liver biopsy. There was no difference in the management of ICI-DILI according to liver biopsy in terms of ICI withdrawal, reduction or rechallenge. According to the histological profile, patients with toxic and granulomatous profiles had a better response to corticosteroids, while patients with cholangitic lesions had the worst response. In ICI-DILI, liver biopsy must not delay patient care but may be useful in identifying patients with a cholangitic profile who have a poorer response to corticosteroids.

Patient-specific quality assurance failure prediction with deep tabular models

Purpose. Patient-specific quality assurance (PSQA) failures in radiotherapy can cause a delay in patient care and increase the workload and stress of staff. We developed a tabular transformer model based directly on the multi-leaf collimator (MLC) leaf positions (without any feature engineering) to predict IMRT PSQA failure in advance. This neural model provides an end-to-end differentiable map from MLC leaf positions to the probability of PSQA plan failure, which could be useful for regularizing gradient-based leaf sequencing optimization algorithms and generating a plan that is more likely to pass PSQA. Method. We retrospectively collected DICOM RT PLAN files of 968 patient plans treated with volumetric arc therapy. We constructed a beam-level tabular dataset with 1873 beams as samples and MLC leaf positions as features. We trained an attention-based neural network FT-Transformer to predict the ArcCheck-based PSQA gamma pass rates. In addition to the regression task, we evaluated the model in the binary classification context predicting the pass or fail of PSQA. The performance was compared to the results of the two leading tree ensemble methods (CatBoost and XGBoost) and a non-learned method based on mean-MLC-gap. Results. The FT-Transformer model achieves 1.44% Mean Absolute Error (MAE) in the regression task of the gamma pass rate prediction and performs on par with XGBoost (1.53 % MAE) and CatBoost (1.40 % MAE). In the binary classification task of PSQA failure prediction, FT-Transformer achieves 0.85 ROC AUC (compared to the mean-MLC-gap complexity metric achieving 0.72 ROC AUC). Moreover, FT-Transformer, CatBoost, and XGBoost all achieve 80% true positive rate while keeping the false positive rate under 20%. Conclusions. We demonstrated that reliable PSQA failure predictors can be successfully developed based solely on MLC leaf positions. FT-Transformer offers an unprecedented benefit of providing an end-to-end differentiable map from MLC leaf positions to the probability of PSQA failure.

NCCN Highlights Best Practices for Challenges in Oncology

NCCN Highlights Best Practices for Challenges in Oncology

PO-01-051 EARLY PHYSICIAN ARRIVAL TO ELECTROPHYSIOLOGY LABORATORY INCREASES LAB EFFICIENCY BY DECREASING PREPARATION TIME

Many cardiac arrhythmia patients benefit from interventions performed in the electrophysiology (EP) lab. EP labs are a valuable resource that if not used efficiently may lead to delay in patient care, increased cost to the medical system, and challenges with recruiting and retaining staff. Prep time is defined as the time from when a patient (pt) enters a procedural room until the procedure start. Prep time is affected by many factors, including but not limited to: pt factors, staffing ratios, sedation plan, need for invasive hemodynamic monitoring, and complexity of procedure (proc). Physician arrival to the EP lab is an important component of prep time. To determine if earlier physician arrival to the EP lab shortens prep time. Pt and physician in-room times, proc start times, and proc characteristics were recorded over a 5 month period from 5/22 through 8/22. Quantitative data was divided into subgroups based on proc type – ablation (abl) or device. Means and standard deviation of physician arrival time and proc start time were calculated. A scatter plot of proc start time compared to physician arrival was created and a best-fit polynomial regression was performed (Fig 1). Point of maximum correlation (PMC) was calculated using Pearson’s method and linear regression was applied from that point onward. Cases that were understaffed and VT ablation were highlighted. Of 539 cases, 235 (44%) were device implants and 304 (56%) were abl. The difference between the earliest average physician arrival time compared to the latest average physician arrival time was 17min for device and 16 min for abl. Prep time was 15 minutes shorter for the earliest arriving physician for device, and 28 min shorter for abl. The PMC for abl and device implants were 25mins and 30mins respectively. Every minute of delay after the PMC was directly related to the MD not being present in the lab. For the interval prior to the PMC, there are many factors causing delays in the lab, leading to questionable direct correlation between MD arrival and prep time. The minimum prep time for both abl and implants appears to be 20 mins in this lab with the current staffing and culture. Earlier MD in room times increase lab efficiency by reducing procedure start times.Tabled 1Mean in Room Times to Access (min) +/-SDAblationDevice ImplantMean Pt Room to EP RoomMean Pt Room to AccessMean Pt Room to EP RoomMean Pt Rm to AccessEP115+/-1347+/-1111+/-1246+/-10EP211+/-942+/-1011+/-942+/-10EP318+/-850+/-1213+/-1647+/-16EP425+/-1449+/-1126+/-2149+/-16EP524+/-1660+/-2021+/-1652+/-14EP68+/-1032+/-84+/-837+/-9EP78+/-831+/-107+/-637+/-7 Open table in a new tab

Healthcare Management System Using Blockchain

Abstract: The current healthcare system has traditionally relied on paper-based medical records or electronic medical records (EMRs) that are stored in centralized databases. This method, however, has shown to be ineffective and unreliable, causing major delays in patient care. Medical documents are frequently sent over email as a temporary fix; however, this approach is unsafe and unreliable. Data breaches or unauthorised access to sensitive patient information pose a serious danger and may have far-reaching repercussions for both patients and healthcare providers. Blockchain technology can provide a more secure, decentralized, and efficient way to store and share medical records. Blockchain offers a tamper-proof and auditable method to trace transactions while using cryptographic methods to secure the integrity and confidentiality of data, access to patient data and modifications. Patients, physicians, and hospitals may easily, anytime, anywhere, and with total safety and security, access medical records via a decentralised blockchain network. Patients have discretion over who gets access to their information and can allow healthcare professionals and organisations access to their medical records. We are employing a number of technologies, like MetaMask, Ganache, Web3JS, and Solidity, to develop a blockchain-based solution. Users may connect with blockchain networks via the browser plugin MetaMask, and a local blockchain development tool called Ganache offers a testing environment for blockchain-based apps. Programmers may interface with the Ethereum blockchain using Web3JS, a JavaScript framework, and Solidity, a language used to create smart contracts the blockchain of Ethereum. A centralised blockchain network that can safely store and distribute patient data is the predicted result of a blockchain-based system for medical record sharing. The system's interoperability and scalability may be ensured via integration with already-existing healthcare systems and databases. Medical record sharing may be automated with smart contracts, allowing for safe and auditable access based on predefined criteria and permissions.

Position paper of the working group Urological Acute Medicine

Emergency patients with acute genitourinary system diseases are frequently encountered in both outpatient and clinical emergency structures. It is estimated that one-third of all inpatients in a urology clinic initially present as an emergency. In addition to general emergency medicine knowledge, specialized urologic expertise is a prerequisite for the care of these patients, which is needed early and specifically for optimal treatment outcomes. It must be taken into account that, on the one hand, the current structures of emergency care still lead to delays in patient care despite positive developments in recent years. On the other hand, most hospital emergency facilities need urologic expertise on site. In addition, politically intended changes in our health care system, which drive an increasing ambulantization of medicine and condition a further centralization of emergency clinics, become effective. The aim of the newly established working group "Urological Acute Medicine" is to ensure and further improve the quality of care for emergency patients with acute genitourinary system diseases and, in consensus with the German Society of Interdisciplinary Emergency and Acute Medicine, to define precise task distributions and interfaces of both specialities.

D153. Improving Operating Room Efficiency Through Reducing First Start Delays in an Academic Center

PURPOSE: Delays in operating room (OR) first case start times can cause additional costs for hospitals, healthcare team frustration and delay patient care. Here, we present our findings on a novel process improvement strategy and its effects on improving first case start times at an academic medical center. METHODS: First case in room start times were recorded for operating rooms at an academic medical center. Three interventions - automatic pre-operative orders, dot phrases to permit re-creation of unavailable consent forms, and improved H&P linking to the surgical encounter - were implemented to target documentation-related delays. Monthly percentages of first case on-time starts (FCOTS) and time saved were compared to the “pre-intervention” time period. Total cost savings from reduced operating room time was also estimated. RESULTS: During the first 3-months after implementation of the interventions, the percentage of FCOTS improved from an average of 36.7% to 52.7%. Total time savings across all operating rooms over the same time period was found to be 55.63 hours, which is estimated to have saved a total of $121,834.52 over the three-month interventional period. CONCLUSION: By implementing multiple quality improvement interventions, delays to first start in room OR cases can be meaningfully reduced. In high volume surgical centers and hospitals, these incremental changes can lead to substantial cost savings in both direct and indirect costs. Understanding the root causes of OR delays and designing quality improvement protocols to target those root causes can ultimately be a significant driver to reduce healthcare costs.

Tool to Track Post-Discharge Lab Results Leads to Improved Rates of Follow Up (P7-7.001)

<h3>Objective:</h3> To improve physician acknowledgement and clinical response times to send-out lab results <h3>Background:</h3> Medical errors lead to thousands of deaths each year. Missing laboratory tests results can contribute to these errors. Factors that may lead to missing results, including improper ordering, numerous handoffs, and a lack of formal system to follow up post-discharge results. We evaluated the efficacy of a tool built into the electronic medical record for results follow up. <h3>Design/Methods:</h3> The residents installed the “Results FYI” tool in Cerner to receive results for patients on whom they had assigned themselves in the role of “resident.” With this tool, any study that results after the patient is discharged appears in the resident’s inbox for review. Common send-out lab results were queried to assess the timeliness with which results were followed up upon, and we compared results from 6 months before and after the tool was implemented. <h3>Results:</h3> In the pre-implementation period, we found that out of the 341 total results, 46 out of 60 positive results were followed up on (76.7%). In the post-implementation period, we found that out of 313 total results, 47 out of 56 positive results were followed up on (83.93%). Overall the average number of days between a lab resulting and the result being acted on decreased in the post-implementation period from an average of 17.59 days to 8.04 days. <h3>Conclusions:</h3> The “Results FYI” tool built into the EMR facilitates faster and more comprehensive follow up on send-out lab results after patients are discharged from the hospital than manually tracking results. Not only were more results followed up on, but it was done in a more timely manner. Universal implementation of this tool will likely lead to faster follow up for study results, leading to fewer adverse delays in patient care. <b>Disclosure:</b> Dr. Kingsford has nothing to disclose. Dr. Hansra has nothing to disclose. Dr. Wiggins has nothing to disclose. Dr. Bryant has nothing to disclose. Dr. Franzen has nothing to disclose. Jay Patel, MD has nothing to disclose. Dr. Greenwood has nothing to disclose. The institution of Dr. Robers has received research support from National Multiple Sclerosis Society. The institution of Dr. Robers has received research support from Bristol Myers Squibb Foundation. The institution of Dr. Robers has received research support from Barrow Neurological Foundation.

MP72-09 SELF-SCHEDULING IMPROVES QUALITY OF CARE FOR HOSPITAL DISCHARGE FOLLOW UP OF URINARY RETENTION PATIENTS

You have accessJournal of UrologyCME1 Apr 2023MP72-09 SELF-SCHEDULING IMPROVES QUALITY OF CARE FOR HOSPITAL DISCHARGE FOLLOW UP OF URINARY RETENTION PATIENTS Avi Baskin, Matthew Chou, Thomas Chi, and Michelle Van Kuiken Avi BaskinAvi Baskin More articles by this author , Matthew ChouMatthew Chou More articles by this author , Thomas ChiThomas Chi More articles by this author , and Michelle Van KuikenMichelle Van Kuiken More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003340.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Delays in patient care after discharge from the hospital can lead to poor quality care and outcomes. At UCSF, one source of patient discontinuity of care has been the inability to consistently obtain an expedited follow up appointment in the urology outpatient clinic after hospital discharge when patients had a new foley placed during their hospital stay. This quality improvement project sought to improve the process for these patients. METHODS: To understand barriers to prompt follow up for patients discharging from UCSF, we employed LEAN A3 methodology. A total of 2 PDSA cycles were completed with two total interventions implemented. The first intervention was to create standing appointments with advanced practice providers that were reserved in the urology clinic for these discharge referrals. The second intervention was the creation of a novel patient self-scheduling approach using the existing electronic medical record. Patients who need referral for a voiding trial with urology were identified by their primary team and a new discharge order was placed. Placement of the referral order generated a ticket in the patient’s portal, allowing patients to select a date and time for their follow up voiding trial. RESULTS: Prior to intervention, there was a median time of 2.0 days from referral placement to appointment scheduling and 9.5 days between referral placement and appointment date. (Figure 1) 20% of patients with referrals were lost to follow up. After the intervention, patients where were scheduled via the self-scheduling work flow had a median of 1.5 days from referral to scheduled appointment compared to 5.5 days from the prior work flow. The post intervention median time between referral placement and appointment scheduling was 8.0 days. 5% of patients in the post intervention period were lost to follow up. CONCLUSIONS: Automation and infrastructure enhancement improved the quality of care and shorted time to follow up for patients who had foley catheters placed during their hospital stay. Efforts like this can be scaled to improve urological quality of care and transitions in care. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1027 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Avi Baskin More articles by this author Matthew Chou More articles by this author Thomas Chi More articles by this author Michelle Van Kuiken More articles by this author Expand All Advertisement PDF downloadLoading ...

Electroconvulsive Therapy in Thrombocytopenic Patients: A Case Report and Literature Review

AbstractIntroductionElectroconvulsive therapy (ECT) continues to be one of the most effective treatments for severe and treatment-resistant major depression. Although there are no absolute contraindications to performing ECT, the risks and benefits need to be assessed in all patients. We present a patient with a history of paroxysmal nocturnal hemoglobinuria (PNH) with significant thrombocytopenia, who completed an index course of six ECT sessions without complication. Currently, there are only two published case reports which describe the use of ECT in patients with thrombocytopenia.MethodsAD is a 37-year-old female with a history significant for MDD, GAD, panic disorder, PNH, and Budd Chiari, who presented to ED for suicidal ideation. Initial labs showed pancytopenia (Hb 4.56 mg/dl, Absolute Neutrophil 0.7 x 103/mL). Given her history of multiple failed SSRIs, ECT was proposed to treat her depression. Anesthesia delayed her initial pre-operative assessment due to concerns regarding her platelet count and risk of bleeding. They recommended transfusion with a preprocedural platelet count goal of 50 x 103/mL. Psychiatry recommended a platelet goal of 20 x 103/mL given previous ECT literature. Patient underwent six ECT sessions without complications. Her platelets ranged from 24–40 x 103/mL and she did not require preprocedural platelet transfusion.ResultsDue to a lack of published literature, there are no formal guidelines for performing ECT in thrombocytopenic patients. The first case report details a 64-year-old female who underwent 12 ECT sessions without complication, while her platelet count ranged from 7–38 x 103/mL. The most recent case report describes a 74-year-old male who underwent nine ECT treatments without complications. The authors decided to transfuse prophylactically if pre-procedure platelet count was less than 20 x 103/mL. The patient underwent nine treatments, requiring eight transfusions. CT head did not show any signs of hemorrhage or structural changes. The authors remarked it is unclear whether the transfusions were necessary.ConclusionsEven though ECT has been in use for over 80 years, there is still much that is unknown about this treatment modality. This case highlights the lack of absolute contraindications to performing ECT. However, the lack of literature and studies regarding platelet goals in thrombocytopenic patients for ECT delayed patient care in this specific case. We add a third case report in a thrombocytopenic patient who underwent ECT without complications with a pre-procedure transfusion criterion if platelet count was less than 20 x 103/mL. More research needs to be conducted to determine risk and cut-off limits for platelet transfusion prior to performing ECT in thrombocytopenic patients.FundingNo funding

Suboptimal Chest Radiography and Artificial Intelligence: The Problem and the Solution.

Chest radiographs (CXR) are the most performed imaging tests and rank high among the radiographic exams with suboptimal quality and high rejection rates. Suboptimal CXRs can cause delays in patient care and pitfalls in radiographic interpretation, given their ubiquitous use in the diagnosis and management of acute and chronic ailments. Suboptimal CXRs can also compound and lead to high inter-radiologist variations in CXR interpretation. While advances in radiography with transitions to computerized and digital radiography have reduced the prevalence of suboptimal exams, the problem persists. Advances in machine learning and artificial intelligence (AI), particularly in the radiographic acquisition, triage, and interpretation of CXRs, could offer a plausible solution for suboptimal CXRs. We review the literature on suboptimal CXRs and the potential use of AI to help reduce the prevalence of suboptimal CXRs.

Deep Learning for Fraud Prediction in Preauthorization for Health Insurance

Health insurance fraud remains a global menace despite the controls implemented to address it; one of such controls is preauthorization. Although, preauthorization promises reduction in fraud, waste and abuse in healthcare, it places undue administrative burden on healthcare service providers and delay in patient care. This limitation has not been thoroughly explored by works of literature in the machine learning domain. In this work, a deep learning model is proposed to learn the preauthorization process for fraud prevention in health insurance for improved process efficacy. In detail, a de-identified HMO preauthorization dataset is used for training the Long Short- Term Memory (LSTM) network. To address class imbalance and avoid data overfitting, the proposed approach utilizes random oversampling and dropout techniques respectively. The experimental results reveal that the proposed model can effectively learn preauthorization request patterns while offering a fraud detection accuracy rate of over 90% with a 2-4% improvement rate in accuracy when compared with previous techniques based on conventional machine learning techniques. The proposed technique is capable of detecting anomalous preauthorization requests based on medical necessity.

Resident pre-dictation of ED case delay signoff of those reports, but overall, residents improve report turnaround time.

In academic radiology departments, attendings and resident are increasingly working together overnight for Emergency Department (ED) radiology coverage. The purpose of this study was to quantify reporting turnaround time for overnight cases read by residents and for overnight shifts with residents on duty. A retrospective study was performed at a hospital system where one overnight attending covers two hospitals with a 2nd/3rd year overnight resident, and a second overnight attending covers two other hospitals 80% of the time independently and 20% of the time with a fourth-year resident. In the first analysis, the median difference in turnaround time, from the time when the case was completed by the technologist to the time the attending finalized it, between cases read independently by attendings and cases pre-dictated by residents was calculated. In the second analysis, the median difference in turnaround time for all cases performed at the second two hospitals was compared on nights when an attending was on duty alone versus nights when a fourth-year resident was also on duty, regardless of if the resident had pre-dictated the case. For computed tomography (CT), radiographs (XR), and ultrasound (US), there was a significant delay in turnaround time for cases pre-dictated by residents compared to cases read independently by attendings, ranging between 11 and 49 min depending on resident seniority and modality (p ≤ 0.001). For all cases on nights with a 4th year resident working, overall median report turnaround time decreased by 7 min (p < 0.001). Resident pre-dictation causes delay in the finalization of individual CT, US, and XR reports; however, overall, working with residents results in a significant decrease in report turnaround time supporting the belief that overnight resident education does not delay patient care.

Development of the Autonomous Nurse Practitioner Role in an Outpatient Malignant Hematology Unit a Twenty-Year Odyssey

Abstract ASH 2022 Development of the autonomous Nurse Practitioner role in an Outpatient Malignant Hematology Unit: A Twenty-Year Odyssey Murray, C., Rowland, S. The Princess Margaret Cancer Centre in Toronto, Ontario is the largest cancer treatment facility in Canada. In 2020, Princess Margaret Cancer Centre received 222,825 clinic visits and treated 82,571 patients. During the year, it received 17,433 new patients, of which 72% required treatment for malignant cancers. These numbers continue to grow. As bed capacity concerns and physician shortages began to create delays in patient care and treatment during the late 1990s a nurse practitioner (NP) was hired to manage the care of leukemia patients in an outpatient setting. The administration of consolidation chemotherapy and follow up monitoring of patients was relocated from the inpatient areas to an ambulatory setting. This initiative proved to be safe and feasible and 'outpatient consolidation' became the standard of care for patients with acute leukemia. During the next 23 years, the Malignant Hematology Day Unit (MHDU) has evolved and now provides care for patients with multiple myeloma, lymphoma, myelodysplastic syndromes and early post transplant allogeneic transplant patients. There are currently 7 NPs working Monday through Friday, and 1 on Saturdays with a total of 15 NPs rotating through the unit. The unit is also staffed with 12 specialized oncology registered nurses, working with the NPs to provide complete patient centered care for 45-60 patients per day. This care includes but is not limited to ordering and administration of chemotherapy, immunotherapy and blood products. The team also manages treatment and transfusion related reactions, febrile neutropenia, infections, pain and end-of-life care. The MHDU is truly 'nurse led'. The Ontario Provincial Legislation allows NPs to independently provide prescriptions to patients (including opioids and other controlled drugs), order and review diagnostic procedures and refer patients to other services such as Respirology or Infectious Diseases. This model of care that has evolved, remains collaborative with physician colleagues ensuring comprehensive patient care. Studies have shown, the use of advanced practitioners, such as NPs, in oncology, is cost effective while continuing the delivery of safe, high quality, patient care. Additionally, with the rapidly evolving treatment options and complexities of these diseases, the utilization of the NPs to monitor and support patients, allows the hematologist time to focus on treatment decisions. This presentation will describe the processes developed to allow for the safe transition of management of a complex patient population to a nurse-led outpatient setting. It will also examine and highlight the positive outcomes of establishing a specialized unit dedicated to the care and management of patients with malignant hematological diseases. These outcomes include, but are not limited to, fewer patients requiring assessment and care in the Emergency Department, less hospital admissions for infections and other complications and improved, seamless end-of-life care

Keep calm and invert on: Reducing blood recollection rates in the neonatal intensive care unit (NICU)

Abstract Background Minimizing blood specimen recollection due to specimen integrity issues is a continuous quality improvement goal in the neonatal intensive care unit (NICU). Specimen integrity issues, such as clotting or hemolysis, are often the result of improper specimen collection processes and lead to blood loss requiring transfusion, additional painful procedures, and delays in patient care. Data collected from Mayo Clinic Hospital - Methodist Campus NICU at Mayo Clinic in Rochester, MN between January – July 2019 showed that clotted complete blood count (CBC) specimens accounted for one-third of rejected neonatal specimens followed by hemolyzed specimens for direct bilirubin (DBIL) testing. The aim of this project was to reduce the percent of CBC and DBIL tests canceled/specimens rejected due to specimen integrity issues in the NICU from 17% to 10% using the Plan-Do-Study-Act methodology. Methods A multidisciplinary quality improvement (QI) team was formed, inclusive of both NICU and laboratory representatives. Bedside direct observations (n=28) were performed by NICU nurses to help identify inconsistencies in the blood collection processes. A total of three Plan-Do-Study-Act (PDSA) cycles were conducted during the 2020-2021 time period. An assessment card was created and revised with each PDSA cycle. The card was completed by the nurse(s) present during the blood collection and initially identified the lab tests ordered, collection tubes, collection type (venipuncture, venous, capillary), number of tube inversions required, staff present during collection, any delays during collection, and whether the draw was deemed successful. Additionally, staff education videos for nursing and laboratory phlebotomy staff were created to demonstrate correct collection tube inversion technique. Results Direct observation identified inconsistent practices in tube inversion during specimen collection. The first PDSA cycle (n=207 collections, April 1 – July 13, 2021) introduced a verbal inversion count and utilization of the assessment card. The following cycle (n=336 collections, July 14 – October 10, 2021) implemented an educational video and modified the assessment card to include start and end time of the draw. The third cycle (n=243 collections, October 11 – November 30, 2021) used a simplified assessment card including patient label, tests ordered, tube type and inversions. The combined rejection rates for CBC and DBIL tests were 4.3%, 3.8% and 2.8% for the 1st, 2nd and 3rd PDSA cycles, respectively. Conclusions Our QI initiative reduced the specimen rejection rate for clotted CBC and hemolyzed DBIL specimens from 17% to 2.8% in the NICU. Interventions focused on improving tube inversion techniques and promoting collaborative relationships between phlebotomists and nursing staff. The use of educational videos and completion of assessment cards during collections were effective at reducing specimen rejection rates.

Extensive Post-EMR Procedure Related Artifact due to Novel Submucosal Lifting Agent, Mimicking Amyloid – A Diagnostic Pitfall

Abstract Introduction/Objective Endoscopic mucosal resection (EMR) techniques are vital for the management of premalignant lesions and early-stage (T1N0) malignant lesions of the digestive tract. Recently FDA approved submucosal lifting agent “ORISE™” (Boston Scientific, Marlborough, MA) for EMR procedure to enable resection of the polyp or lesion. We herein present two hemicolectomy cases performed for a colon cancer showing an exuberant amyloid-like reaction due to ORISE™ Gel. Methods/Case Report At Veterans Affairs Medical Center, two cases of hemicolectomy were performed for colon cancer. Both cases had prior EMR procedure performed for a large cecal polyp. ORISE™ gel was injected with successful lift of the polyp during EMR. Pathology on both cases revealed tubulovillous adenoma with high grade dysplasia; hence right hemicolectomy was performed. Microscopic examination revealed submucosal area with extensive amorphous, eosinophilic/hyaline deposits and surrounding giant cell formation, underlying the cancerous polyp. The deposits were neither refractile nor polarizable. No tattoo pigmentation identified to explain this reaction. The fibrillary eosinophilic deposit raised the concern for concurrent amyloid deposits. This stained pale blue with Masson trichome special stain. Congo red special stain for amyloid was negative and no apple-green birefringence under polarized light was identified. Finally, after extensive ancillary work-up with literature review, the case was signed out as “changes consistent with post-EMR ORISE™ gel artifact”. Results (if a Case Study enter NA) N/A. Conclusion Knowledge of EMR procedure artifact due to use of ORISE™ gel is crucial in routine hemicolectomy specimens performed for unresectable polyps or colon cancer cases. ORISE™ gel creates amorphous hyaline deposits mimicking amyloid. The deposits encompass larger submucosal area with giant cells mimicking foreign body. Delay in turn around time of the case with additional cost for the ancillary work-up. Extensive amyloid-like reaction is a diagnostic pitfall in routine hemicolectomy specimens and, awareness of prior EMR procedure related artifact is important to avoid misinterpretation and delay in patient care.