Initial Triage Research Articles

Establishing Triage Competencies and Verification Processes: A Survey Study

IntroductionAlthough the ED triage function is a critical means of ensuring patient safety, core competencies for ED triage are not well defined in the literature. The purpose of the study was to identify and validate emergency triage nursing competencies and to develop a competency verification process. MethodsA sample of 1181 emergency nurses evenly divided between roles with oversight of triage training and competency assessment (manager-level and staff nurses performing triage) completed an online survey evaluating competency elements that comprised the following in terms of frequency and importance, training modalities, and evaluation methods: expert assessment, clinical judgment, management of medical resources, communication, and timely decisions. ResultsBoth manager-level and triage nurses agreed on the importance of the identified competencies. Gaps in training and evaluation were reported by both staff nurses and manager-level nurses. Triage nurses reported less training offered and less competency evaluation compared with manager-level nurses. Triage nurses reported performing all competencies more frequently and at higher level of competency than manager-level nurses reporting on triage nurse performance. DiscussionThis study provides both a standard set of triage competencies and a method by which to evaluate them. Managers and educators might consider this standard to establish initial triage role competency and periodic competency assessment per institutional guidelines. The gap in perceived education and evaluation suggests that standard education and evaluation processes be adopted across emergency departments.

The “Inboxologist” — A Novel Approach to In-Basket Management in Primary Care

Primary care providers are spending more time responding to electronic patient requests and completing other tasks in their digital in-basket that do not require their level of expertise. This contributes to job dissatisfaction and burnout. Last year, at two large primary care practice sites, Corewell Health West implemented a pilot program that introduced a new in-basket triage system involving a registered nurse completing initial triage and an advanced practice provider serving as an “inboxologist.” Under this model, primary care providers handled 41% fewer in-basket messages than before the pilot and spent an average of 47% less time on the messages they did receive. Self-reported time spent on the in-basket during office hours and after office hours decreased by an average of 37% and 32%, respectively. The number of messages that were resolved by the nonphysician staff member who initially triaged the message increased by 14.2% from pre-pilot to the end of the pilot period. Time to resolution of patient-generated messages decreased by 93%, with subsequent improvement in patient satisfaction scores. Given the favorable reception by physicians, patients, and staff, Corewell plans to expand the inboxologist program to all of its primary care sites and to selected specialty practices.

Role of MDCT in Patients with Abdominal Trauma

Objectives: To assess the role of abdominal imaging for precise identification of the injuries for early surgical exploration by using Multidetector Computed Tomography (MDCT) and to assess those patients that can be managed conservatively. Study Design: Prospective cross-sectional observational study. Place and Duration of the Study: Pakistan Air Force Hospital Islamabad, November, 2022-November, 2023. Methodology: The study was carried out on 120 cases of abdominal trauma. MDCT scan with contrast was performed after the initial resuscitation and stability of the patients in the emergency room being done by the respective medical and paramedical staff. Results: In clinically stable patients, the use of multi-detector CT as initial triage of abdominal trauma resulted in a reduction in the number of laparotomies by 91% and an increase in number of conservatively managed with a better outcome of around 95% and 92% respectively. Conclusion: The current study assessed and showed the better role of MDCT in evaluation of the blunt trauma patients in early detection and timely surgical exploration. MDCT imaging test helps the clinicians in making an early and right choice of intervention. The high-resolution MPR, MIP, and 3-D volume reconstruction images assisted in displaying complex injuries, increasing diagnostic capacity, accuracy, associated vascular and bony pathologies, and reduced reporting time.

Area of admission and short-term care: is it still possible after the COVID pandemic?

Dear Editor, Since 2011, the Internal Medical Unit of Ospedale dell’Angelo, Mestre, has been equipped with an area of eight beds which served as a short-stay unit called area di accoglimento e degenza breve (area of admission and short-term care, ADB). All patients coming from the emergency room (99%) passed through the ADB area. Here, doctors and nurses carried out an initial clinical care triage to identify patients with features that made the discharge possible within 72 hours. [...]

Triage Discordance in an Academic Pediatric Emergency Department and Disparities by Race, Ethnicity, and Language for Care

Background Minoritized patients are disproportionately represented in low-acuity emergency department (ED) visits in the United States in part caused by lack of timely access to primary and urgent care. However, there is also the possibility that implicit bias during triage could contribute to disproportionate representation of minority groups in low-acuity ED visits. Triage discordance, defined as when ED resources used are different from initial triage score predictions, can be used as a proxy for triage accuracy. Recent data suggest that discordant triage may be common, although little is known about the interaction with race, ethnicity, and language for care. Objectives This study aims to determine the prevalence of discordant triage among moderate- and low-acuity pediatric ED encounters and the interaction with patient race, ethnicity, and language for care. Methods We performed a retrospective analysis of pediatric ED encounters from 2019 with Emergency Severity Index (ESI) scores of 3, 4, or 5 at an academic referral hospital. The primary outcome was triage discordance, encompassing overtriage (ESI 3 and 4) and undertriage (ESI 4 and 5). Logistic and multinomial regressions were used to assess discordant triage by race, ethnicity, and language group. Results Triage discordance occurred in 47% (n = 18,040) of encounters. Black and Hispanic patients had higher likelihood of undertriage for ESI 5 (adjusted odds ratio 1.21, 95% confidence interval [CI] 1.01–1.46 and 1.27, 95% CI 1.07–1.52, respectively), and Black patients were more likely to be overtriaged in ESI 3 (1.18, 95% CI 1.09–1.27). Those with a language other than English for care had higher proportions of overtriage for ESI 3 (1.08, 95% CI 1.04–1.12) and undertriage for ESI 5 (1.23, 95% CI 1.11–1.37). Conclusions We found high rates of triage discordance in our pediatric ED, with significant associations with race, ethnicity, and language for care. Future research should evaluate the source of triage discordance and develop quality improvement efforts to improve equitable care.

Characteristics and risk of stroke in emergency department patients with acute dizziness

BackgroundAcute dizziness is a common symptom in the emergency department (ED), with strokes accounting for 3 %–5 % of cases. We investigated the risk of stroke in ED patients with acute dizziness and compared stroke characteristics diagnosed during and after the ED visit. MethodsWe identified adult patients with acute dizziness, vertigo, or imbalance using a hospital research-based database. Patients with abdominal or flank pain were used as the comparison group. Patients with dizziness were 1:1 matched to comparison patients. Each patient was traced for up to one year until being hospitalized for a stroke. ResultsOut of the 24,266 eligible patients, 589 (2.4 %) were hospitalized for stroke during the ED visit. For the remaining 23,677 patients, the risk of stroke at 7, 30, 90, and 365 days after ED discharge was 0.40 %, 0.52 %, 0.71 %, and 1.25 % respectively. Patients with dizziness had a higher risk of stroke compared to the comparison group at 7, 30, 90, and 365 days. The risk ratios decreased from 5.69 (95 % confidence interval [CI], 3.34–9.68) to 2.03 (95 % CI, 1.65–2.49). Compared to patients hospitalized for stroke during the ED visit, those hospitalized for stroke after the ED visit had greater stroke severity despite a lower initial triage acuity. Patients with early stroke (≤7 days) after ED discharge were less likely to have hypertension, diabetes, hyperlipidemia, and atrial fibrillation. They mostly experienced posterior circulation stroke. Patients with late stroke (>7 days) were older and less likely to have hypertension and hyperlipidemia but more likely to have a history of prior stroke and ischemic heart disease. Their strokes were mainly located in the anterior circulation territory. ConclusionsThe risk of stroke after ED discharge was higher in patients with dizziness than in the comparison group, with gradually decreasing risk ratios in the following year. Patients hospitalized for stroke during and after the ED visit had different profiles of vascular risk factors and clinical characteristics.

Self-referral to musculoskeletal physiotherapy in the National Health Service (NHS): a mixed methods, four-domain analysis of 1,000 adult new patients initially assessed via telephone versus face-to-face

Introduction In some regions, NHS patients are able to self-refer to physiotherapy. Initial assessment and triage of these referrals is via telephone (PhysioDirect) or face-to-face (Physio Access Clinic). There is currently a scarcity of literature comparing both methods in physiotherapy triage. A multi-domain mixed-methods comparison was conducted to evaluate cost, outcomes & satisfaction of both methods. Method Data was collected for telephone and face-to-face self-referrals from October 2021 to February 2022 and analysed to compare patient outcome, patient satisfaction, physiotherapist perception and cost between both delivery methods. Results Outcomes were analysed across 2402 total patient contacts, with face-to-face assessment showing improved outcomes in all areas compared to telephone assessment. Patient satisfaction was greater following face-to-face assessment than telephone. Physiotherapists showed greater satisfaction, greater diagnostic confidence, greater feeling of support and improved learning with a face-to-face approach. Scaled to 150 patients per week face-to-face only was associated with an annual saving of over £40,000 compared to telephone only initial assessment. This is equivalent to 1503 physiotherapist hours and 550 administrative hours. Conclusion Patients self-referring to musculoskeletal physiotherapy via a face-to-face clinic have improved outcomes with greater reported satisfaction. Physiotherapists preferred face-to-face appointments in all facets examined within this study. A significant annual cost saving was evident through face-to-face contact which is especially relevant in the current economic climate of the NHS. Given these notable advantages of face-to-face triage over telephone triage, these findings could inform the planning of future physiotherapy provision.

An Education and Training Program on Disaster Triage for Nurses and Nursing Students: Literature Review

Natural disasters continue to increase globally yearly. Over 1.6 billion people live in disaster-prone areas, conflict zones, and displacement areas. The impacts of disasters highlight the importance of disaster preparedness to minimize errors in disaster triage management. However, nurses' knowledge and skills in implementing initial triage procedures are still adequate. This scooping review aims to find an overview of implementing disaster triage education and training programs. This research is a scooping review using the Prisma flow chart in its implementation. This study showed significant results in all articles (n = 14) in increasing knowledge, attitudes, skills, awareness, preparedness, accuracy, and learning motivation in conducting disaster triage. The methods used are simulation methods (live, virtual reality, and screen-based) and training and education methods (lectures, discussions, videos, roleplay, and games) with material on disaster triage, START triage, and SALT triage concepts. This study concluded that disaster triage education for nurses and nursing students is very important to be provided by carrying out the latest methods so that the results are more effective.

Assisted teleconsultation in an outpatient pharmacy: Results of a pilot study in Geneva, Switzerland.

Assisted teleconsultation (ATC) is the act of telemedicine involving on one side a patient in the presence of a healthcare professional, and an expert on the other side. ATC in outpatient pharmacies may be an alternative to the emergency room for patients with a semi-urgent medical problem. This project aimed at pilot testing the ATC in an outpatient pharmacy to assess its feasibility and to collect initial real-world data. After initial evaluation and triage by the pharmacist, ATC was proposed to patients consulting at one outpatient pharmacy for semi-urgent medical problems. Prospective data on patients, consultation reasons, teleconsultation duration, patient's orientation and pharmacist' satisfaction were prospectively collected. Between December 2020 and June 2021, 39 consultations took place, 12 with video and 27 with telephone. Patients' median age was 37 years (IQR 26-50), 59% were women. Near half of the consultations (19) happened during the weekend. Mean ATC duration was 22 min (IC95% 18.6-26.1). Twenty-nine (74%) consultations ended with a prescription, 8 (21%) with medical recommendations and 2 (5%) with an emergency care referral. Without teleconsultation, 34 (87%) patients would have consulted a physician for their problem, and 24 (62%) would have been to the emergency room (self-reported). Fourteen (36%) consultations involved ENT, ophthalmologic and dermatologic complaints. A young population with semi-urgent medical problems can be managed in the pharmacy using ATC with a primary care physician. Financial, technical and training aspects should be developed and optimized in the future.

Assessment of the concordance between DN4 scores performed by the patient (self-assessment) or by the physician (hetero-assessment) to detect subacute neuropathic postoperative pain.

Centres dedicated to chronic postsurgical pain (CPSP) have been developed, but delays for accessing to it are generally long. Teleconsultation might be a means to facilitate access to care by allowing an initial triage. CPSPs are neuropathic pain in around half of the cases and their diagnosis is mainly based on the score obtained from validated questionnaires. Among them, those requiring a neurological examination (i.e. the Douleur Neuropathique en 4 questions [DN4]) have a better sensitivity and specificity, and should be preferred. However, effectiveness of a remote neurological examination remains to be established. The aim of this observational study is to check during a face-to-face consultation if, after a short training, a naïve patient is capable to self-assess the clinical signs of neuropathic sensations. Thirty patients with suspected neuropathic pain were seen in a face-to-face postoperative pain consultation. Before examination, the patient was instructed to fill the DN4 questionnaire, including the neurological examination. Once explanations were given and checked, the patient was left and completed it alone. Then, the pain physician performed the DN4 questionnaire. Inter-rater reliability between patient and pain physician was assessed for each item and for DN4 score with the Kappa coefficient. For each item of the DN4 questionnaire, Kappa coefficients were between 0.74 and 1, and could be considered as excellent. For DN4 ≥ 4, the Kappa coefficient was 0.86. Our results suggest that after a short training, a naïve patient is capable of recognizing and diagnosing symptoms of neuropathic pain. Our results suggest that self-assessment, carried out after brief training and using a simple tool, provides results comparable to those obtained by a specialist physician to diagnose symptoms of neuropathic pain. If the results of the current study are confirmed on a larger scale, self-assessment will help improve access to specialized chronic pain care by better orienting patients and opening up access to teleconsultations.

Psychometric properties of the COVID-19 Yorkshire Rehabilitation Scale: Post-Covid-19 syndrome in Iranian elderly population

BackgroundThis study aimed to assess the construct validity and reliability of the Iranian version of the COVID-19 Yorkshire Rehabilitation Scale (C19-YRS) among the elderly population.MethodA cohort of 230 elderly individuals who tested positive for Covid-19 via PCR were administered a health and demographic information questionnaire along with the C19-YRS. Both exploratory and confirmatory factor analyses were conducted, and Cronbach’s alpha was calculated.ResultsFindings from the exploratory and confirmatory factor analyses of the C19-YRS revealed alterations compared to the original version, resulting in an adapted version with three factors achieved by redistributing the questions. These factors accounted for 57.46% of the total variance. Despite a relatively lower factor loading in the 6th question, it was retained due to its significance among the elderly. The Cronbach’s alpha for the C19-YRS subscales ranged from 0.730 to 0.890, indicating acceptable reliability.ConclusionThe validation results indicated a well-adjusted factor structure and internal consistency, affirming the utility of this tool among the elderly population. Consequently, the C19-YRS in Iran can serve as a valuable resource in healthcare settings, aiding in the assessment of chronic complications arising from Covid-19 in the elderly. It can be utilized as an initial screening or triage test and to evaluate the effectiveness of interventions.

Implementing a comprehensive STEMI protocol to improve care metrics and outcomes in patients with in-hospital STEMI: an observational cohort study

BackgroundPatients who experience in-hospital ST-segment elevation myocardial infarction (iSTEMI) represent a uniquely high-risk cohort owing to delays in diagnosis, prolonged time to reperfusion and increased mortality. Quality initiatives aimed at...

Comparison of qSOFA, MEDS, and APACHE II Scores in Early Identification of Sepsis for Patients with 28 days Mortality and ICU Admission: A cross-sectional Study

Introduction: Sepsis is a life-threatening infection that results in organ dysfunction due to an increased pathogen load, necessitating urgent intervention. There is a gap in clinicians’ ability to identify septic patients at high-risk with poor outcomes, highlighting the need for validated predictive scores for early intervention, favourable outcomes, and prompt recovery. Aim: To validate the predictive capacity of the Sequential Organ Failure Assessment (qSOFA), Mortality in Emergency Department Sepsis (MEDS), and Acute Physiology and Chronic Health Evaluation (APACHE 2) scores in patients with 28- day mortality and in Intensive Care Unit (ICU) patients due to sepsis. Materials and Methods: This cross-sectional study was conducted on 150 septic patients at the Department of Emergency Medicine, Sri Ramachandra Institute of Higher Education and Research in Chennai, India, between June and December 2022. Parameters assessed included Respiratory Rate (RR), Systolic Blood Pressure (SBP), Mean Arterial Pressure (MAP), temperature, White Blood Cell (WBC) count, platelet count, bilirubin, and creatinine. Descriptive analysis of age, gender, source, RR, GCS, SBP, qSOFA, MEDS, APACHE 2 in 28-day mortality, and ICU patients. Positive correlation and good predictivity of predictive scores (qSOFA, MEDS, APACHE 2) were analysed using Spearman’s Rank Correlation Coefficient (SRCCRs) statistical test in 28-day mortality and ICU patients. Results: A total of 150 septic patients (male: female-93:57) with an average age of 57.07±14.4 years were included. Urosepsis was the most common (n=51), followed by respiratory sepsis (n=48). Of these, 96 patients were admitted to the ICU, and 54 patients experienced 28-day mortality. The average and median values of RR were 27.1±7.64 breaths/minute (b/m) and 26 b/m, respectively. SBP values were 106.13±30.47 mmHg and 110 mmHg, respectively. Diastolic Blood Pressure (DBP) values were 66±16.51 mmHg and 60 mmHg, respectively. The average and median values of GCS were 12.75±3.92 and 15, respectively. The average for qSOFA was 29.1±0.025, with a median of 28; for MEDS, the average was 7.99±5.89, with a median of 7; and for APACHE 2, the average was 16.74±9.64, with a median of 15. Spearman’s Rank Correlation Coefficient (SRCCRs) demonstrated a strong positive correlation and good predictive validity between qSOFA, MEDS, and APACHE 2 scores in 28- day mortality and ICU patients (<0.001). Receiver Operating Characteristic Curve (ROC) analysis indicated good predictive validity for qSOFA in 28-day mortality and ICU patients. Conclusion: qSOFA exhibited a positive correlation and good predictive validity compared to MEDS and APACHE 2 in both 28-day mortality and ICU patients (<0.001). This study highlights the utility and applicability of qSOFA at the bedside for initial triage, as it can be quickly employed with minimal information.

Recommendations for assessing appearance concerns related to plexiform and cutaneous neurofibromas in neurofibromatosis 1 clinical trials.

Individuals with neurofibromatosis 1 may experience changes in their appearance due to physical manifestations of the disorders and/or treatment sequelae. Appearance concerns related to these physical changes can lead to psychological distress and poorer quality of life. While many neurofibromatosis 1 clinical trials focus on assessing changes in tumor volume, evaluating patients' perspectives on corresponding changes in symptoms such as physical appearance can be key secondary outcomes. We aimed to determine whether any existing patient-reported outcome measures are appropriate for evaluating changes in appearance concerns within neurofibromatosis 1 clinical trials. After updating our previously published systematic review process, we used it to identify and rate existing patient-reported outcome measures related to disfigurement and appearance. Using a systematic literature search and initial triage process, we focused on identifying patient-reported outcome measures that could be used to evaluate changes in appearance concerns in plexiform or cutaneous neurofibroma clinical trials in neurofibromatosis 1. Our revised Patient-Reported Outcome Rating and Acceptance Tool for Endpoints then was used to evaluate each published patient-reported outcome measures in five domains, including (1) respondent characteristics, (2) content validity, (3) scoring format and interpretability, (4) psychometric data, and (5) feasibility. The highest-rated patient-reported outcome measures were then re-reviewed in a side-by-side comparison to generate a final consensus recommendation. Eleven measures assessing appearance concerns were reviewed and rated; no measures were explicitly designed to assess appearance concerns related to neurofibromatosis 1. The FACE-Q Craniofacial Module-Appearance Distress scale was the top-rated measure for potential use in neurofibromatosis 1 clinical trials. Strengths of the measure included that it was rigorously developed, included individuals with neurofibromatosis 1 in the validation sample, was applicable to children and adults, covered item topics deemed important by neurofibromatosis 1 patient representatives, exhibited good psychometric properties, and was feasible for use in neurofibromatosis 1 trials. Limitations included a lack of validation in older adults, no published information regarding sensitivity to change in clinical trials, and limited availability in languages other than English. The Response Evaluation in Neurofibromatosis and Schwannomatosis patient-reported outcome working group currently recommends the FACE-Q Craniofacial Module Appearance Distress scale to evaluate patient-reported changes in appearance concerns in clinical trials for neurofibromatosis 1-related plexiform or cutaneous neurofibromas. Additional research is needed to validate this measure in people with neurofibromatosis 1, including older adults and those with tumors in various body locations, and explore the effects of nontumor manifestations on appearance concerns in people with neurofibromatosis 1 and schwannomatosis.

A Proposed Approach to Allegations of Sexual Boundary Violation in Health Care.

Sexual boundary violations in the health care setting cause harm for victims, threaten an organization's culture, and create extraordinary organizational risk. The inherent complexities of health care organizations present unique challenges for the initial triage and response to reports of alleged violations. A group of experts with experience in law, leadership, human resources, medicine, and health care operations identified processes for organizations to triage and implement an early response to allegations of sexual boundary violations. The group reviewed a series of 100 reports of alleged violations described by patients and coworkers from a 200-hospital professional accountability collaborative to identify the elements of an ideal initial triage and management approach. The group identified three domains to guide early triage and response to reports of boundary violations: (1) severity and acuity of the alleged violation; (2) roles and relationship(s) of the complainant, respondent, and other affected individuals; and (3) contextual information such as prior activity or other mitigating factors. The group identified leadership engagement; coordinated responses; clear articulation of values, policies, and procedures; aligned data reporting; thoughtful reviews; and securing appropriate resources as essential elements of an organization's response. A structured systematic approach to classify and respond to allegations of sexual boundary violation is described. The initial response should be guided by assessment of the severity and timing of the reported behavior, followed by assessment of roles and responsibilities with involvement of all relevant stakeholders. Contextual issues and special circumstances of relevance should be identified and incorporated into the response. Systems to identify, store, and retrieve behavior of concern should be improved and integrated.

Building an Extracorporeal Cardiopulmonary Resuscitation Program at a High-volume Extracorporeal Membrane Oxygenation Center

Extracorporeal Cardiopulmonary Resuscitation (ECPR) is an emerging approach to cardiac arrest. We present two contrasting cases from a high-volume extracorporeal membrane oxygenation (ECMO) center (defined as greater than 30 ECMO cases per year) without a 24/7 ECPR program to highlight how to establish an ECPR program with a focus on patient selection and outcome optimization. In one case, a patient presented with cardiac arrest during initial triage for chest pain within the emergency department, and in the other case, a patient experienced an out-of-hospital cardiac arrest with prolonged no-flow and low-flow time. Despite the lack of a 24/7 ECPR program at the presenting center, both patients received an ECPR evaluation, as both patients presented while all services necessary for ECMO cannulation were available. The in-hospital cardiac arrest patient was successfully cannulated for ECMO during cardiopulmonary resuscitation and survived with few complications. The out-of-hospital cardiac arrest patient was deemed a poor candidate for ECPR and expired soon after presentation. These two cases highlight the complex decision-making in ECPR and further illustrate how to create ECPR protocols at a high-volume ECMO center before resources are available for a 24/7 ECPR program.

Challenges in handling a civilian mass pediatric disaster during flood relief in a partially inundated armed forces medical facility.

Armed forces hospitals are often called upon to provide medical aid to civilians during natural calamities. Though children are often the most vulnerable segment of population in these events, research that addresses their unique needs and the role of armed forces hospitals remains sparse. We examined pediatric morbidity and mortality at a flooded armed forces hospital. Factors that affected outcomes were identified. 158 patients were evacuated en masse from a children's hospital in northern India that was submerged by flood to an adjacent partially inundated armed forces hospital specializing in military medicine and adult trauma. The children were provided case-based clinical care as per existing disaster management protocol. Geoclimatic vulnerability factors, morbidity/mortality, and medical and logistical challenges for future intervention were investigated. One pediatrician who provided initial triage was joined by two others after 48 hours. A limited load of adult patients permitted more resources for the children, majority (49 percent) of whom were neonates. Intensive care was necessitated for 32 (20.2 percent) cases, with half managed in adult ICU. Overall in-hospital mortality was 5.7 percent. Experienced staff, cross-specialty multitasking, and innovative and noncensorious leadership were identified as assets amidst resources compromised by flooding. Clear delineation of primary caregiver role of pediatrician at outset, pediatric emergency care training, pediatric triage, resource allocation for thermoregulation, oxygen therapy and ventilation, earmarking centers for transfer of cases, and safe transportation to the centers were identified as areas meriting further attention. Armed forces hospitals in vulnerable geoclimatic zones must address pediatric concerns in disaster management plans.

Lymphoma triage from H&E using AI for improved clinical management

AimsIn routine diagnosis of lymphoma, initial non-specialist triage is carried out when the sample is biopsied to determine if referral to specialised haematopathology services is needed. This places a heavy...

Abstract 15437: Use of Artificial Intelligence to Decrease Data Deluge From Remote Monitoring of Cardiac Implantable Electronic Devices

Background Remote monitoring (RM) has become the standard of care for follow up of patients with cardiac implantable electronic devices (CIED). Data deluge from RM of CIEDs is one of the major challenges faced by the cardiac device clinics. This study explores the role of a novel artificial intelligence (AI) algorithm in reducing the data deluge from CIED. Methods: The study included remote transmissions from CIEDs being monitored at 78 clinics across USA from Jan 2023 to April 2023. De-identified data was obtained from the data repository of Octagos Health. The transmissions were initially processed by AI algorithm and were either dismissed, forwarded to the device technician (DT) for review or forwarded directly to the device clinics. The main reasons for dismissals were redundant data or clinically non-actionable and non billable information. After initial triage by AI algorithm, the DT served as the second checkpoint who either dismissed or forwarded the transmissions to the device clinic with and without alerts. Results: A total of 42,534 patients with CIEDs were included in this study. There were 19,895 (46.8%) patients with pacemakers, 8,858 (20.8%) with ILRs, 7,012 (16.5%) with ICDs, 5,028 (11.8%) with CRT-D and 1,741 (4.1%) with CRT-P. Over a period of 4 months of RM, 273,435 transmissions were received. Of these, 57,345 (21%) transmissions were dismissed by AI and 118,546 (43.4%) were dismissed by the device technician team. As such only 97,544 (35.7%) transmissions were sent to the clinicians, of which 37,627 (13.8%) had alerts while 59,917 (21.9%) were routine transmissions. For quality control, about 15% (11,324) transmissions were randomly verified by EP for accuracy and were found to be 99% (11,193/11,324) accurate. Conclusion In our study, the use of AI algorithm significantly decreased data deluge by appropriate triaging of RM data from CIEDs. This has a potential to streamline the workflow of cardiac device clinics and improving efficiency and patient care.

Changing Strategy Between Bridge to Transplant and Destination LVAD Therapy After the First 3 Months: Analysis of the STS-INTERMACS Database

Background: Left ventricular assist devices (LVADs) have been implanted as bridge to transplantation (BTT), bridge to candidacy (BTC) or destination therapy (DT) based on relative and absolute contraindications to transplantation. Multiple factors may lead to change in the strategy of support after LVAD implantation. Methods: From INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) 2012-2020, 11,262 patients survived to 3 months on continuous flow LVADs with intent of BTT or DT. Pre-implant characteristics and early events post-LVAD were analyzed in relation to changes in BTT or DT strategy during the next 12 months. Results: Among 3216 BTT patients at 3 months, later transplant de-listing or death without transplant occurred in 536 (16.7%) and, was more common with age, Profiles 1-2, renal dysfunction, and independently for prior cardiac surgery (HR 1.25, 95% CI 1.04-1.51, p = 0.02). Post-LVAD events of infections, gastrointestinal bleeding, stroke, and right heart failure defined by inotropic therapy predicted de-listing and death, as did in-hospital location at 3 months (HR 1.67, 95% CI 1.20-2.33, p =0.0024). Of 8046 patients surviving to 3 months with intent as destination therapy, 750 (9.3%) subsequently underwent listing or transplant, often with initial history of acute HF (HR 1.70, 95% CI 1.27-2.27, p = 0.0012) or malnutrition-cachexia (1.73, 95% CI 1.14-2.63, p = 0.0099). Multiple gastrointestinal bleeding events (≥4) with LVAD increased transition from BTT to DT (HR 4.22, 95% CI 1.46-12.275, p = 0.0078) but also from DT to BTT (HR 5.17, 95% CI 1.92-13.9, p = 0.0011). Conclusions: Implant strategies change over time in relation to pre-implant characteristics and adverse events post implant. Pre-implant recognition of factors predicting later change in implant strategy will refine initial triage, while further reduction of post-LVAD complications will expand options including eventual consideration of heart transplant.