Workflow Improvement Research Articles

Efficacy of remote consultation between hospital cardiologists and primary care in cardiovascular disease management: the "Cardiologia in linea" project in Trentino, Italy

Telemedicine enables patients to receive better care via the simplification of procedures while allowing for a significant reduction of in-office appointments and emergency room visits. The "Cardiologia in linea" project started with the objective of strengthening communications between cardiologists and primary care, particularly with general practitioners. Between January 2017 and October 2022, by means of a facilitated telephonic and digital contact between territorial professionals and the cardiologist, the project provided in most cases immediate answers to cardiology queries, which were logged. A total of 2066 telephonic or digital consultations have been recorded, originating from 316 general practitioners in the Trento province (Italy). The mean age of patients was 76.4 years, 53% were male. After consultation, an immediate response was provided in 1989 (96%) of cases. A total of 1112 (54%) cardiology visits were avoided. After the consultation, a cardiologic visit was suggested in 29 cases (1%), and the emergency system was activated in 20 cases (1%). Overall, most questions concerned direct oral anticoagulant prescriptions (537 cases, 31%) and anti-hypertensive treatment (241 cases, 14%). The "Cardiologia in linea" project demonstrated a low-cost improvement in the patient assistance workflow, in the communication between hospital cardiology and primary care, while reducing the number of emergency room accesses. The project successfully shows the feasibility of a real-time dialogue between the general practitioner and the hospital cardiologist.

Pharmaceutical Residual Solvent Analysis: A Comparison of GC-FID and SIFT-MS Performance

Residual solvents in pharmaceutical excipients, active pharmaceutical ingredients (APIs), and finished products are usually analyzed using gas chromatography (GC)-based techniques according to a pharmacopeial monograph, such as the United States Pharmacopeia’s (USP) chapter <467>. GC analyses are often slow, which limits sample throughput. Selected ion flow tube mass spectrometry (SIFT-MS) removes the rate-limiting chromatographic separation step, potentially offering faster sample analyses. This approach was demonstrated recently with the publication of an alternative SIFT-MS procedure which was successfully validated against the performance criteria in USP chapter <1467>. The present study expands upon the previous work by conducting a head-to-head comparison of GC-flame ionization detection (GC-FID) and SIFT-MS procedures. The results obtained in this cross-platform study demonstrated similar performance for the GC-FID and SIFT-MS procedures for linearity (R2 > 0.94 and 0.97, respectively) and repeatability (<17%RSD and <10%RSD). For accuracy and recovery, acceptance criteria (within 20%) were achieved for most compounds across the two drug products (SIFT-MS suffered fewer failures, possibly due to shorter wait times prior to analysis). Additionally, SIFT-MS analyzed samples over 11-fold faster than GC-FID, increasing daily sample throughput and reducing the time taken to determine the result. This study therefore suggests that residual solvent analysis using SIFT-MS may support workflow improvements for pharmaceutical manufacturers.

Determinants of an integrated cervical cancer screening services in primary healthcare: sharing lessons from Kisumu, Kenya.

The successful integration of cervical cancer screening service (CCASS) into primary healthcare's routine services depends on locality-specific and context-based service determinants. This paper aims to identify the abovementioned determinants and discusses how health administrators can manage their influence on CCASS delivery at the primary healthcare level. We conducted in-depth face-to-face interviews using a structured questionnaire with CCASS nurse providers and managers in four randomly selected primary health facilities. Information on the method(s) of screening utilised, the challenges faced, and the changes observed in CCASS provision were collected. Service managers were asked how they managed unplanned CCASS disruption, factors influencing CCASS replication, and aftercare support to cancer-affected women. Nurse providers were interviewed on the management of CCASS awareness and critical changes required to sustain CCASS service effectiveness. We used a constant interactive and inductive approach for data analysis. Nine thematic categories of CCASS determinants were identified: 'cultural', 'socioeconomic', 'individual', 'health system', 'evidence-based operations', 'outcome-based resourcing', 'workflow improvement and standardisation', 'inclusive partner's management', 'utilisation'. These determinants were grouped into three domains: 'conceptual', 'outcomes', and 'growth' domains, to correspond to clusters of determinants that are likely to influence the CCASS lifecycle in its formative, continuous delivery or productivity, and reproductive phases. The findings show that sustaining an efficient integrated CCASS delivery at the PHC level requires phase-appropriate continuous adaptive improvements of service determinants within that locality. Nine thematic categories of CCASS determinants were identified: 'cultural', 'socioeconomic', 'individual', 'health system', 'evidence-based operations', 'outcome-based resourcing', 'workflow improvement and standardisation', 'inclusive partner's management', 'utilisation'. These determinants were grouped into three domains: 'conceptual', 'outcomes', and 'growth' domains, to correspond to clusters of determinants that are likely to influence the CCASS lifecycle in its formative, continuous delivery or productivity, and reproductive phases. The findings show that sustaining an efficient integrated CCASS delivery at the PHC level requires phase-appropriate continuous adaptive improvements of service determinants within that locality.

Precellys® Evolution Homogenizer - a versatile instrument for milling, mixing, and amorphization of drugs in preformulation

The aim of this work was the evaluation and introduction of the Bertin Precellys® Evolution homogenizer with Cryolys® as a valuable and versatile tool for the improvement of workflows in the preformulation phase of drug development. The presented pilot experiments indicate that the instrument can be applied for (1) screening of appropriate vehicles for the generation of micro- and nano suspensions, (2) small-scale manufacturing of suspension formulations for preclinical animal studies, (3) drug amorphization and identification of appropriate excipients for amorphous systems, and (4) preparation of homogenous powder blends. The instrument allows the rapid, parallel, and compound-sparing screening of formulation approaches and small-scale formulation manufacturing, in particular for low solubility compounds. For the characterization of generated formulations, miniaturized methods are introduced such as a screening tool for suspension sedimentation and redispersion and a non-sink dissolution model in biorelevant media in microtiter plates. This work summarizes exploratory, proof-of-concept studies and opens up new opportunities for more extended studies with this instrument in various application areas.

Effect of Workflow Improvements on Time to Endovascular Thrombectomy for Acute Ischemic Stroke in the MR CLEAN Registry

BackgroundInsight in the effect of workflow improvements can help to minimize the time between onset of ischemic stroke and start of endovascular thrombectomy (EVT). The authors aimed to assess the implementation of EVT workflow strategies and their effect on time to treatment.MethodsThe authors used data from the MR CLEAN (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands) registry and included patients with acute ischemic stroke in the anterior circulation, who underwent EVT between March 2014 and November 2017. Data on implementation of 20 predefined workflow improvement strategies during the study period were collected from each intervention center. Multilevel linear regression with a random intercept for center was used to quantify the effect of each strategy on door‐to‐groin puncture time, with adjustment for calendar time, for directly presented and transferred patients separately.ResultsThe authors included 2633 patients who were treated in 14 intervention centers. Of the 20 predefined strategies, 18 were actually implemented in ≥1 centers during the study period. In directly presented patients (n=1157), the intervention with the largest effect on door‐to‐groin puncture time was a strategy to avoid sedation during EVT compared with standard use of general anesthesia, which led to a reduction of 29% (95% CI, 6–46;P=0.02), corresponding to a decrease of 26 minutes (95% CI, 5–42). In transferred patients (n=1476), the interventions with the largest decrease in door‐to‐groin puncture time were a strategy to make the decision for patient transfer to the angiosuite after 1 stroke physician assessed the imaging, instead of both interventionist and neurologist (47% [95% CI, 5–70]; 19 minutes [95% CI, 2–29]) (P=0.03), and a strategy to perform neurological assessment at the angiosuite instead of the emergency department (32% [95% CI, 19–43]; 13 minutes [95% CI, 8–17]) (P<0.001).ConclusionIntervention centers have implemented multiple new strategies to improve their workflow. Such workflow improvements lead to substantial reductions in time to EVT and may thereby improve the outcome of patients with acute ischemic stroke.

Current status of endovascular treatment for older adults with acute large vessel occlusion stroke in China: subgroup analysis of ANGEL act registry.

Although endovascular treatment (EVT) has become the standard treatment for acute large vessel occlusion (LVO), its safety and efficacy in older adults have not been fully determined. The present study aimed to compare the safety and efficacy of EVT for acute LVO between younger (<80 years old) and older adults (≥80 years old) in the Chinese population. The subjects were selected from the ANGEL-ACT registry (endovascular treatment key technique and emergency workflow improvement of acute ischemic stroke). The 90-day modified Rankin score (mRS), successful recanalization, procedure duration, number of passes, intracranial hemorrhage (ICH), and mortality within 90 days were compared after adjusting for confounders. A total of 1,691 patients, 1,543 classified as young and 148 classified as older, were included. We observed that young and older adults had a similar 90-day mRS distribution, successful recanalization, procedure duration, number of passes, ICH, and mortality within 90 days (all p > 0.05). The rate of 90-day mRS 0-3 was found to be higher in young patients than in older adults (39.9% vs. 56.5%, odds ratio = 0.64, 95% confidence interval = 0.44-0.94, p = 0.022). We found that patients less than or greater than 80 years of age share similar clinical outcomes, without increasing the risk of ICH and mortality.

Does MRI add value in selecting patients for thrombectomy beyond the 6 h window? A matched-control analysis.

Controversy exists regarding the need of advanced imaging for patient selection in the extended window. To analyze the effect of initial imaging modalities on clinical outcomes of patients underwent MT in the extended window. This was a retrospective analysis of a prospective registry, the Endovascular Treatment Key Technique and Emergency Workflow Improvement of Acute Ischemic Stroke (ANGEL-ACT) registry which was conducted at 111 hospitals between November 2017 and March 2019 in China. Primary study cohort and Guideline like cohort were identified, in each cohort, two imaging modalities for patient selection in 6 to 24 h window were defined: (1) NCCT ± CTA, (2) MRI. Guideline-like cohort were further screened based on key features of the DAWN and DEFUSE 3 trials. The primary outcome was 90 day mRS. The safety outcomes were sICH, any ICH and 90-day mortality. After adjusting for covariates, there were no significant differences in 90 day mRS or any safety outcomes between two imaging modalities groups in both cohorts. All outcome measures of mixed-effects logistic regression model were consistent with propensity score matching model. Our results indicate that patients presented with anterior large vessel occlusion in the extended time window can potentially benefit from MT even in the absence of MRI selection. This conclusion needs to be verified by the prospective randomized clinical trials.

Application the Kanban Cards and the Value Stream Map (Vsm) to Rationalize Inventory Costs and to Improve The Company's Performance and Oversight Applied Research in Electrical Cables Factory / Ur State Company For Electrical Industries

Purpose: This research aims to try to application the two cards (kanban) system and the value stream map in the electrical cables factory in the Ur Company for Electrical Industries, with the intention of rationalizing the storage costs and improving the production, marketing and warehouse process to get rid of waste, and loss in time and cost. Theoretical framework: This research problem emerged due to the lack of The factory application of these systems that work to solve the problem of storage accumulation as well as improving the progress of the production process, and the research hypothesis has proven that it is possible to apply the Kanban system and the value stream map in the plant under discussion. Design/methodology/approach: The research showed the most important conclusions, including stock accumulation of various types, reduction of inventory, improvement of work flow, improvement in response to changes in customer requests, reduction of risk of obsolescence of inventory, reduction of the percentage of spoilage from (3%) to (2%), and rationalization of total production inventory from 858 tons [26 tons × 31 days] to 806 tons [ 26 tons x 33 days]. Findings: application the two cards (kanban) system and the value stream map in the electrical cables factory in the Ur Company for Electrical Industries The improvement in the current status of the Value Stream map, to the future status was carried out according to the Kaizen Burst (continuous improvements). As for the most important recommendations, Research, Practical &amp; Social implications: The improvement in the current status of the Value Stream map, to the future status was carried out according to the Kaizen Burst (continuous improvements). Originality/value: This study is one of the very few studies that focus on the concept of cards (kanban) system and the value stream map it was necessary to implement the Kanban and value map system in the Cables electric plant, activating the state of transparency in the production and marketing work and facilitating the work The administrator and the need to open communication channels between the administration and workers to take advantage of the proposed views, reconsider the incentive system and link it to performance and to encourage workers to excel and drive innovation and creativity.

Impact of virtual visits on primary care physician work flows.

To understand the impact of virtual visits on primary care physician (PCP) work flows. Qualitative semistructured interviews. Primary care practices within 5 regions in southern Ontario. Physicians representing primary care practices of various sizes and remuneration models (eg, capitation and fee-for-service models). Interviews were conducted with PCPs involved in a large-scale pilot project implementing virtual visits (via a Web-based application) into clinical practices. Convenience and purposive sampling were used to recruit PCPs between January 2018 and March 2019. To obtain a representative sample, participants were sought from a variety of practice types and geographic regions. High and low users of virtual visits were included. Interviews were audiorecorded and transcribed. An inductive thematic analysis was used to identify prominent themes and subthemes. Twenty-six physicians were interviewed (n=15 using convenience sampling and n=11 through purposive sampling). Four themes were identified: PCPs employ diverse approaches to integrate virtual care into their work flow; PCPs recognize that implementing virtual visits requires upfront time and effort but have variable perceptions regarding long-term impact of virtual care on processes; asynchronous messaging is preferable to synchronous audio or video visits; and strategies were identified to improve the integration of virtual visits. The potential of virtual care to improve work flow is dependent on the way these visits are implemented and used. Dedicated time for implementation, emphasis on using asynchronous secure messaging, and access to clinical champions and structured change management support were associated with more seamless integration of virtual visits.

Cost-effectiveness of improvement strategies for reperfusion treatments in acute ischemic stroke: a systematic review

BackgroundReducing delays along the acute stroke pathway significantly improves clinical outcomes for acute ischemic stroke patients eligible for reperfusion treatments. The economic impact of different strategies reducing onset to treatment (OTT) is crucial information for stakeholders in acute stroke management. This systematic review aimed to provide an overview on the cost-effectiveness of several strategies to reduce OTT.MethodsA comprehensive literature search was conducted in EMBASE, PubMed, and Web of Science until January 2022. Studies were included if they reported 1/ stroke patients treated with intravenous thrombolysis and/or endovascular thrombectomy, 2/ full economic evaluation, and 3/ strategies to reduce OTT. The Consolidated Health Economic Evaluation Reporting Standards statement was applied to assess the reporting quality.ResultsTwenty studies met the inclusion criteria, of which thirteen were based on cost-utility analysis with the incremental cost-effectiveness ratio per quality-adjusted life year gained as the primary outcome. Studies were performed in twelve countries focusing on four main strategies: educational interventions, organizational models, healthcare delivery infrastructure, and workflow improvements. Sixteen studies showed that the strategies concerning educational interventions, telemedicine between hospitals, mobile stroke units, and workflow improvements, were cost-effective in different settings. The healthcare perspective was predominantly used, and the most common types of models were decision trees, Markov models and simulation models. Overall, fourteen studies were rated as having high reporting quality (79%-94%).ConclusionsA wide range of strategies aimed at reducing OTT is cost-effective in acute stroke care treatment. Existing pathways and local characteristics need to be taken along in assessing proposed improvements.

Improvement of Workflows and Assay Reproducibility by The Introduction of "Assay-Ready" Culturing of MDCK Cells for Transport Studies.

In previous studies, we established and validated three Madin Darby Canine Kidney MDCKII cell lines, recombinantly modified with zinc finger nuclease (ZFN) technology. Here, we investigated the applicability of seeding these three canine P-gp deficient MDCK_ZFN cell lines, directly from frozen cryopreserved stocks without previous cultivation for efflux transporter and permeability studies. This technique is referred to as "assay-ready" and allows for highly standardized conduction of cell-based assays and shorter cultivation cycles. To obtain a rapid fitness of the cells for that purpose, a very gentle freezing and thawing protocol was applied. Assay-ready MDCK_ZFN cells were tested in bi-directional transport studies and compared to their traditionally cultured counterparts. Long-term performance robustness, human effective intestinal permeability (Peff) predictability and batch to batch variability were assessed. Efflux ratios (ER) and apparent permeability (Papp) results were highly comparable between assay-ready and standard cultured cell lines with R2 values of 0.96 or higher. Papp to Peff correlations obtained from passive permeability with non-transfected cells were comparable independent of the cultivation regime. Long-term evaluation revealed robust performance of assay-ready cells and reduced data variability of reference compounds in 75% of cases compared to standard cultured MDCK_ZFN cells. Assay-ready methodology for handling MDCK_ZFN cells allows more flexibility in assay planning and reduces performance fluctuations in assays caused by cell aging. Therefore, the assay-ready principle has proven superior over conventional cultivation for MDCK_ZFN cells and is considered as a key technology to optimize processes with other cellular systems.

Image analysis of cutaneous melanoma histology: a systematic review and meta-analysis

The current subjective histopathological assessment of cutaneous melanoma is challenging. The application of image analysis algorithms to histological images may facilitate improvements in workflow and prognostication. To date, several individual algorithms applied to melanoma histological images have been reported with variations in approach and reported accuracies. Histological digital images can be created using a camera mounted on a light microscope, or through whole slide image (WSI) generation using a whole slide scanner. Before any such tool could be integrated into clinical workflow, the accuracy of the technology should be carefully evaluated and summarised. Therefore, the objective of this review was to evaluate the accuracy of existing image analysis algorithms applied to digital histological images of cutaneous melanoma.Database searching of PubMed and Embase from inception to 11th March 2022 was conducted alongside citation checking and examining reports from organisations. All studies reporting accuracy of any image analysis applied to histological images of cutaneous melanoma, were included. The reference standard was any histological assessment of haematoxylin and eosin-stained slides and/or immunohistochemical staining. Citations were independently deduplicated and screened by two review authors and disagreements were resolved through discussion. The data was extracted concerning study demographics; type of image analysis; type of reference standard; conditions included and test statistics to construct 2 × 2 tables. Data was extracted in accordance with our protocol and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Diagnostic Test Accuracy (PRISMA-DTA) Statement. A bivariate random-effects meta-analysis was used to estimate summary sensitivities and specificities with 95% confidence intervals (CI). Assessment of methodological quality was conducted using a tailored version of the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. The primary outcome was the pooled sensitivity and specificity of image analysis applied to cutaneous melanoma histological images. Sixteen studies were included in the systematic review, representing 4,888 specimens. Six studies were included in the meta-analysis. The mean sensitivity and specificity of automated image analysis algorithms applied to melanoma histological images was 90% (CI 82%, 95%) and 92% (CI 79%, 97%), respectively. Based on limited and heterogeneous data, image analysis appears to offer high accuracy when applied to histological images of cutaneous melanoma. However, given the early exploratory nature of these studies, further development work is necessary to improve their performance.

Current practices and perspectives on the integration of contrast agents in MRI-guided radiation therapy clinical practice: A worldwide survey

AimsThe introduction of on-line magnetic resonance image-guided radiotherapy (MRIgRT) has led to an improvement in the therapeutic workflow of radiotherapy treatments thanks to the better visualization of therapy volumes assured by the higher soft tissue contrast. Magnetic Resonance contrast agents (MRCA) could improve the target delineation in on-line MRIgRT planning as well as reduce inter-observer variability and enable innovative treatment optimization protocols. The aim of this survey is to investigate the utilization of MRCA among centres that clinically implemented on-line MRIgRT technology. MethodsIn September 2021, we conducted an online survey consisting of a sixteen-question questionnaire that was distributed to the all the hospitals around the world equipped with MR Linacs. The questionnaire was developed by two Italian 0.35 T and 1.5 T MR-Linac centres and was validated by four other collaborating centres, using a Delphi consensus methodology. ResultsThe survey was distributed to 52 centres and 43 centres completed it (82.7%). Among these centres, 23 institutions (53.5%) used the 0.35T MR-Linac system, while the remaining 20 (46.5%) used the 1.5T MR-Linac system.According to results obtained, 25 (58%) of the centres implemented the use of MRCA for on-line MRIgRT. Gadoxetate (Eovist®; Primovist®) was reported to be the most used MRCA (80%) and liver the most common site of application (58%). Over 70% of responders agreed/strongly agreed to the need for international guidelines. ConclusionsThe use of MRCA in clinical practice presents several pitfalls and future research will be necessary to understand the actual advantage derived from the use of MRCA in clinical practice, their toxicity profiles and better define the need of formulating guidelines for standardising the use of MRCA in MRIgRT workflow.

Abstract P3-04-06: Artificial intelligence-based triaging of breast cancer screening mammograms and radiologist workload reduction: a systematic review and meta-analysis

Abstract Introduction: Deep learning (DL) has shown promising results for mammographic breast cancer diagnosis. However, the impact of artificial intelligence (AI) in the screening process have not yet been fully addressed in terms of workload reduction, which has potential to decrease healthcare disparities. Radiologists are tasked with overwhelming volumes of screening mammograms, particularly in medically underserved areas. Therefore, when applied to workflow improvement, AI might be a tool to reduce healthcare disparities. The purpose of this systematic review and meta-analysis was to assess if AI-based triaging of breast cancer screening mammograms could reduce the radiologist’s workload with non-inferior sensitivity. Methods: PubMed, EMBASE, Cochrane Central and Web of Science databases were systematically searched for studies that evaluated AI algorithms on computer-aided triage of breast cancer screening mammograms. We extracted data from homogenous studies and performed a proportion meta-analysis with random-effects model to verify the radiologist’s workload reduction and the software’s sensitivity. Results: A total of 14 studies were systematically selected. Three studies using the same commercially available DL algorithm were included in the meta-analysis, with 156852 examinations evaluated at the threshold of 8. The radiologist’s workload decreased by 68.3% (95%CI 0.655-0.711, I² = 98.76%, p &amp;lt; 0.001), with a sensitivity of 93.1% (95%CI 0.882-0.979, I² = 83.86%, p = 0.002). Conclusion: Our findings suggest that DL computer-aided triage of breast cancer screening mammograms significantly reduces the radiologist’s workload with high sensitivity. Although AI’s implementation remains complex and heterogeneous, it is a promising tool to optimize healthcare resources with a potential large impact in low resource settings that struggle with workforce shortage. Citation Format: Debora Xavier, Isabele A. Miyawaki, Carlos Alberto Campello Jorge, Matheus Jose Barbosa Moreira, Bruno M. Carvalho, Felipe Batalini. Artificial intelligence-based triaging of breast cancer screening mammograms and radiologist workload reduction: a systematic review and meta-analysis [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P3-04-06.

Benchmarking performance of an automatic polysomnography scoring system in a population with suspected sleep disorders.

The current gold standard for measuring sleep disorders is polysomnography (PSG), which is manually scored by a sleep technologist. Scoring a PSG is time-consuming and tedious, with substantial inter-rater variability. A deep-learning-based sleep analysis software module can perform autoscoring of PSG. The primary objective of the study is to validate the accuracy and reliability of the autoscoring software. The secondary objective is to measure workflow improvements in terms of time and cost via a time motion study. The performance of an automatic PSG scoring software was benchmarked against the performance of two independent sleep technologists on PSG data collected from patients with suspected sleep disorders. The technologists at the hospital clinic and a third-party scoring company scored the PSG records independently. The scores were then compared between the technologists and the automatic scoring system. An observational study was also performed where the time taken for sleep technologists at the hospital clinic to manually score PSGs was tracked, along with the time taken by the automatic scoring software to assess for potential time savings. Pearson's correlation between the manually scored apnea-hypopnea index (AHI) and the automatically scored AHI was 0.962, demonstrating a near-perfect agreement. The autoscoring system demonstrated similar results in sleep staging. The agreement between automatic staging and manual scoring was higher in terms of accuracy and Cohen's kappa than the agreement between experts. The autoscoring system took an average of 42.7 s to score each record compared with 4,243 s for manual scoring. Following a manual review of the auto scores, an average time savings of 38.6 min per PSG was observed, amounting to 0.25 full-time equivalent (FTE) savings per year. The findings indicate a potential for a reduction in the burden of manual scoring of PSGs by sleep technologists and may be of operational significance for sleep laboratories in the healthcare setting.

Improving Identification of Interpreter Need in the Pediatric Emergency Department.

Patients with limited English proficiency (LEP) benefit from the appropriate use of medical interpreters. A multidisciplinary quality improvement team sought to improve communication with patients with LEP within a pediatric emergency department (ED). Specifically, the team aimed to improve the early identification of patients and caregivers with LEP, the utilization of interpreter services for those identified, and documentation of interpreter use in the patient chart. Using clinical observations and data review, the project team identified key processes for improvement in the ED workflow and introduced interventions to increase identification of language needs and offer interpreter services. These include a new triage screening question, an icon on the ED track board that communicates language needs to staff, an electronic health record (EHR) alert with information on how to obtain interpreter services, and a new template to prompt correct documentation in the ED provider's note. Outcomes were tracked using statistical process control charts. All study measures met special cause for improvement during the 6-month study period and have been sustained during surveillance data collection. Identification rates for patients with LEP during triage increased from 60% to 77%. Interpreter utilization increased from 77% to 86%. The documentation of interpreter use increased from 38% to 73%. Using improvement methods, a multidisciplinary team increased the identification of patients and caregivers with LEP in an ED. Integration of this information into the EHR allowed for the targeted prompting of providers to use interpreter services and to correctly document their use.

Evaluation of the portability of computable phenotypes with natural language processing in the eMERGE network

The electronic Medical Records and Genomics (eMERGE) Network assessed the feasibility of deploying portable phenotype rule-based algorithms with natural language processing (NLP) components added to improve performance of existing algorithms using electronic health records (EHRs). Based on scientific merit and predicted difficulty, eMERGE selected six existing phenotypes to enhance with NLP. We assessed performance, portability, and ease of use. We summarized lessons learned by: (1) challenges; (2) best practices to address challenges based on existing evidence and/or eMERGE experience; and (3) opportunities for future research. Adding NLP resulted in improved, or the same, precision and/or recall for all but one algorithm. Portability, phenotyping workflow/process, and technology were major themes. With NLP, development and validation took longer. Besides portability of NLP technology and algorithm replicability, factors to ensure success include privacy protection, technical infrastructure setup, intellectual property agreement, and efficient communication. Workflow improvements can improve communication and reduce implementation time. NLP performance varied mainly due to clinical document heterogeneity; therefore, we suggest using semi-structured notes, comprehensive documentation, and customization options. NLP portability is possible with improved phenotype algorithm performance, but careful planning and architecture of the algorithms is essential to support local customizations.

Abstract TMP46: Large Vessel Occlusion Stroke Knowledge And Clinical Training In Emergency Medical Service Personnel In The United States

Background: Stroke education of emergency medical service (EMS) personnel improves stroke recognition, prenotification, and thrombolytic delivery. Prehospital identification of large vessel occlusion (LVO) stroke may facilitate the creation of a regional bypass protocol and improvement of intrahospital and interhospital workflows. However, the current status of EMS personnel’s knowledge of LVO, their stroke severity assessment training, and preferences in educational methods have not been studied. We conducted an EMS survey across the United States. Methods: The Society of Vascular and Interventional Neurology (SVIN) in collaboration with EMS-World created an online questionnaire distributed to all subscribers of EMS-World involved in pre-hospital work. It included 12 multiple-choice questions to test participants on LVO knowledge, stroke center certification levels, prior LVO education, and preferences on educational content delivery. Results: The survey email was opened by 1830 subscribers out of whom 1107 (60%) completed the survey across 50 states in the United States. Respondents identified themselves as paramedics/EMTs (91.4%), ground critical care (5.7%) and flight crew (2.9%). The number of stroke patients that survey participants transported in the past year was &lt;10 for 618 (55.8%), 10 to 25 for 332 (30%), and &gt;25 (14.2%). Two hundred eighty-five (25.8%) participants answered both LVO knowledge questions correctly and 379 (34.2%) answered one correctly. Only 128 (11.6%) correctly identified all types of centers with thrombectomy capability. Although 877 (79.2%) were familiar with at least one stroke severity scale, 376 (34%) denied receiving training to perform them. Five sixty-seven (51.2%) respondents preferred in-person training for LVO training and 429 (38.8%) an online training program. About half of all respondents (535,48%) picked 'lack of standardized LVO training' as the greatest hurdle to pre-hospital LVO management. Conclusion: EMS providers in the United States reported inadequate LVO training and demonstrated gaps in knowledge of LVO, stroke severity scales, and stroke center levels. Systematic efforts to enhance and standardize the educational content and delivery of LVO education are urgently needed.

Futile reperfusion of endovascular treatment for acute anterior circulation large vessel occlusion in the ANGEL-ACT registry

BackgroundSome patients with large vessel occlusion (LVO) still cannot achieve functional independence despite successful reperfusion after endovascular treatment (EVT), named futile reperfusion. We aimed to explore the incidence and predictors...

Incidence, predictors, and impact on outcome of underlying intracranial atherosclerotic disease in acute vertebrobasilar artery occlusion undergoing endovascular therapy: Data from ANGEL-ACT registry.

Intracranial atherosclerotic disease (ICAD) is a common etiology of acute vertebrobasilar artery occlusion (VBAO) in Asia, which complicated endovascular treatment (EVT). We aimed to investigate the incidence, impacts, and predictors of ICAD in VBAO. Subjects were selected from the Endovascular Treatment Key Technique and Emergency Work Flow Improvement of Acute Ischemic Stroke registry and divided into two groups based on whether underlying ICAD existed. Underlying ICAD was determined when the following situations arise in the occlusion site during EVT: (1) fixed stenosis degree >70% or (2) stenosis >50% with distal blood flow impairment or evidence of repeated reocclusion. Multivariable regression models were used to investigate the effect of underlying ICAD on outcomes measured by modified Rankin Scale (mRS) score at 90 days and to identify baseline characteristics associated with underlying ICAD. Among the 315 patients enrolled, 171 (54.3%) had underlying ICAD. Favorable functional outcomes (mRS 0-3) occurred in 79 of 163 patients (48.5%) with ICAD and 69 of 137 patients (50.4%) without ICAD (p = 0.743). Outcomes were similar between the two groups and remained similar after adjusting for the confounders. History of hypertension and elevated admission neutrophil to lymphocyte ratio were strong predictors of underlying ICAD, whereas history of atrial fibrillation and distal basilar artery occlusion were negative predictors. In our study, underlying ICAD was recognized in approximately half of the VBAO patients, leading to comparable outcomes after more complex EVT strategies. Some baseline characteristics were identified to be predictors for underlying ICAD, which were helpful to guide the EVT strategies before the procedure.