Major Cause Of Delay Research Articles

Real-World Analysis of Barriers to Timely Administration of Chimeric Antigen Receptor T Cell (CAR T) Therapy in Diffuse Large B-cell Lymphoma

The implementation of chimeric antigen receptor T (CAR T) therapy in the real-world setting is hindered by logistical and financial barriers, impacting timely access to this life-saving treatment. Clinical trials have reported the time from leukapheresis to CAR T cell infusion (vein-to-vein time) but not the time from CAR T referral to infusion (decision-to-vein time). Herein, we report the barriers to CAR T therapy in a real-world setting. We evaluated the factors influencing the decision-to-vein time and explored the association with clinical outcomes in patients with relapsed or refractory diffuse large B cell lymphoma (DLBCL) who received CAR T therapy. We conducted a retrospective study of adult patients with relapsed/refractory DLBCL who underwent consultation for CAR T cell therapy at Levine Cancer Institute and Wake Forest Comprehensive Cancer Center and collected information regarding demographic data, referral type, insurance type, CAR T product, and survival outcomes. The effects of variables on decision-to-vein time were analyzed by Fisher's exact test for categorial variables and Wilcoxon rank-sum test for continuous variables. Survival analyses were performed using Kaplan-Meier and Cox Proportional Hazard models. The study included 142 patients who were referred for CAR T of which 99 patients received CAR T. Median decision-to-vein time was 62 days compared to median vein-to-vein time of 32 days. Patients with private insurance took longer to obtain financial clearance compared to patients with government insurance (median 25 versus 9 days, P < .001). Of those with private insurance (n = 63), 35% needed a single-case agreement (SCA) which led to significant delay in receiving financial clearance (median 50.5 versus 19 days, P < .001) and increased decision-to-vein time (median 75 versus 55 days, P < .001) compared to those who did not need SCA. Decision-to-vein time was significantly different among various products, clinical trial being the shortest (median 47 days, n = 9) and non-conforming products being the longest (median 94.5 days, n = 6) (P< .001). Axi-cel had the shortest median decision-to-vein time at 61 days compared to 81 days with tisa-cel and 85 days with liso-cel. Although delays in receiving CAR T therapy did not impact survival, the median overall survival for patients who were referred for CAR T therapy but did not receive it, was significantly lower than those who received CAR T cell therapy (9.0 versus 21.0 months, P < .001). Decision-to-vein time is a major cause of delay in receiving CAR T therapy. SCAs lead to significant increase in decision-to-vein time leading to delays in CAR T therapy in a real-world setting. Patients who were referred for CAR T but are not able to receive it, have inferior survival compared to CAR T recipients. Our findings underscore the significance of addressing administrative hurdles, such as SCAs and insurance approvals, for timely access to CAR T therapy for patients with DLBCL.

Deployment of vaccine cold chain equipment in resource-limited settings: lessons from the Gavi Cold Chain Optimization Platform in Cameroon.

Lack of or use of suboptimal cold chain equipment (CCE) is a major barrier to optimal immunization coverage and equity. Gavi established the CCE optimization platform (CCEOP) in 2015 to help eligible countries modernize their cold chain systems. However, there are limited data on CCE deployment at country level. We present lessons learnt from deploying CCE from the Gavi CCEOP in Cameroon. This cross-sectional study collected data on the number of days items of CCE spent at each point on their trajectory from the entry port to 62 randomly selected health facilities in Cameroon. Once equipment arrived at the entry port, it took 10 d for customs clearance, 2 d from customs clearance to warehousing and 257 d (>9 mo) from the warehouse to facilities. Upon arrival at the facilities, it took a median of 53 (range 0-395) d from installation to final commissioning: most of the days (median=210) were spent between installation and final commissioning. The major causes of delays included insufficient coordination and communication across all levels, poor documentation and final commissioning. Early engagement on customs clearance, strengthening coordination and communication, ensuring proper documentation, as well as eliminating final commissioning, could significantly improve implementation of the program.

Third delay in care of critically ill patients: a qualitative investigation of public hospitals in Kenya

ObjectivesThird delay refers to delays in delivering requisite care to patients after they arrive at a health facility. In low-resource care settings, effective triage and flow of care are difficult...

Health-seeking behaviour of breast cancer patients receiving care at a tertiary institution in Ghana.

Breast cancer incidence rates are rising in Africa and mortality is highest in West Africa. Reasons for poor survival are multifactorial but delays in seeking appropriate health care result in late presentation which contributes significantly to poor outcomes. Total delays of more than 3 months have been associated with advanced stage at presentation and poorer survival. A cross-sectional design was used to assess delays in health-seeking behaviour in consecutive breast cancer patients receiving treatment at Korle Bu Teaching Hospital (KBTH) from January to December 2022 using a structured, interviewer-administered questionnaire. Data were gathered to assess health-seeking behaviour in relation to delays in a presentation to a health care facility, and factors that may have influenced the delays. Statistical analysis was done using descriptive and inferential analyses. The study involved 636 participants with a mean age and SD of 52.6 ± 12 years. Most participants were diagnosed with Stage 3 or 4 breast cancer (56.5%). Ninety percent of participants had visited at least one health facility prior to seeking care at KBTH. Forty-two percent of the participants sought care at a health facility less than a month after noticing symptoms of breast cancer while 34.4% did so greater than 3 months after noticing symptoms. Delays showed a significant association with age, marital status, educational level, average monthly income and cancer stage (p < 0.05). Common reasons for delays were lack of knowledge of breast cancer signs and/or symptoms (47%), advice from family and friends (15%), financial difficulties (9%), seeking alternate treatments (7%), competing priorities (6%) and indifference (5%). Lack of knowledge about breast cancer was a major cause of delay in seeking health care in this study. Education should specifically target knowledge about breast cancer and the need for appropriate and timely health seeking.

Accelerating patient recruitment using social media: Early adopter experience from a good clinical practice-monitored randomized controlled phase I/IIa clinical trial on actinic keratosis

BackgroundPatient recruitment is a major cause of delays in randomized controlled trials (RCT). Online recruitment is evolving into an alternative to conventional in-clinic recruitment for RCT. The objective of this study was to test the effectiveness of online patient recruitment for an RCT on actinic keratosis (AK). MethodsIn this proof-of-concept study, adults with AK were recruited for a Phase I/IIa RCT (NCT05164393) via social media using targeted advertising Interested users were directed to a landing page to learn about the study, respond to questionnaires, and upload self-obtained smartphone pictures of potential AK. Facebook Analytics was used to track the number of advertisement views, individual users exposed to the advertisement, and advertisement clicks. Following eligibility-review by remote dermatologists, candidates were contacted for an in-clinic visit. A review of pertinent RCTs on AK (2012–2022) was conducted to compare recruitment metrics. ResultsThe online campaign served 886,670 views, reached 309,000 users, and generated 27,814 clicks. A total of 556 users underwent eligibility review, leading to 140 pre-evaluated potential study subjects. The RCT's enrollment target of 60 patients (68.8 ± 7.1 years, 43.3 % female) was reached in 53 days after screening 90 participants in-clinic, corresponding to a screen failure rate of 33.3 %. The total cost of this online recruitment campaign was 14,285 USD i.e. 238 USD per randomized patient. Compared to the existing literature (44 RCTs), our online approach resulted in 9 times more time-efficient recruitment per site. ConclusionUsing targeted advertisements, 60 patients with AK were recruited for a single-center Phase I/IIa RCT in 53 days. Social media appears to be an efficient platform for online recruitment of patients with low-grade AK for RCT.

Health related quality of life in adults after late repair of tetralogy of fallot: experience from a low-middle income country.

Without neonatal screening in low middle-income countries like Pakistan, Tetralogy of Fallot (TOF) is a congenital heart disease which frequently remains untreated beyond infancy. The purpose of this study is to determine and assess outcomes and health related quality of life (HRQOL) in patients who undergo complete repair of TOF as adults. 56 patients who underwent complete TOF repair after 16years of age were included. Patient data was collected via retrospective chart review, and a semi structured interview along with Short-Form 36 (SF-36) questionnaire were used to assess HRQOL. 66.1% of patients were male with the mean age at surgery of 22.3 ± 6.00. All patients had a post-operative NYHA Classification of I or II, 94.6% had an ejection fraction of ≥ 50% and 28.6% showed small residual lesions in follow-up echocardiograms. 32.1% of patients suffered post-operative morbidity. For the quantitative assessment using SF-36 scores, patients showed good scores of median 95 (65-100). A major cause of delay to treatment was lack of consensus between treatments offered by doctors in different parts of Pakistan. There was a pattern of 'inability to fit in' among patients who had had late TOF repair, despite self- reported improved HRQOL. Our results indicate that even with a delayed diagnosis, surgical repair of TOF produces good functional results. However, these patients face significant psychosocial issues. While early diagnosis remains the ultimate goal, patients undergoing late repair should be managed in more holistic manner with attention to psychological impact of the disease as well.

Effects of Lubrication on Wear and Rolling Contact Fatigue Behavior of Class B Wheel Steels Against R350HT Rail Steels Using a Twin-Disc Wear Simulator

Wear and rolling contact fatigue (RCF) are major causes of delays and unavailability of rail systems. The presence of lubricants at the rail and wheel interface influences wear and RCF. Lubricants include naturally occurring types, such as water from rain and leaves from trees next to rail lines, and materials applied on purpose to help improve adhesion and friction, such as friction modifiers, greases, and traction gels. The aim of this work was to study the wear behavior of AAR class B wheel versus R350HT rail materials in the presence of water and oil in comparison with the dry condition. There is currently a lack of knowledge regarding the combination of these materials in a twin-disc simulator, and this work provides information on their impact on RCF and wear performance for use by the rail industries. It was found that wear was much lower when water or oil was introduced at the wheel–rail interface compared to dry conditions, for all slip ratios. When water was used, the main cause of RCF was found to be fluid crack pressurization. The RCF cracks were also observed under dry contact.

Assessment of Client-Related Factors for Delaying of Public Buildings Constructions Projects in Local Government Authorities: A Case of Arusha City Council

This study aimed to assess client-related factors for delaying of Public buildings construction projects in Local Government Authorities. The factors assessed were; project design, political intervention and decision-making challenges. The study was conducted at Arusha City Council (ACC) employing cross-sectional survey through semi-structured questionnaire and interview guide to 55 sampled informants. . Cross tabulation with Chi-square tests was deployed to analyse data. Following the findings of the assessment of client-related factors for delaying of public buildings construction projects in Arusha City Council, it is concluded that inadequate project design is one of the major causes of delays of public buildings construction projects in local government authorities. More specifically, variations due to inadequate design, the effect of insufficient budget resulting from inadequate project design and insufficient professional staff are the main causes of delays in public buildings constructions project. It is also apparent that political intervention is another major factor that contributes to delaying public building construction in Arusha City council (ACC). It is also concluded that decision making challenges is another major contributor to delaying public building construction projects in ACC. More specifically, it is concluded that bureaucracy in the decisions making process, unnecessary directives by government officials and delays in the payment of interim certificates are the main causes of delaying public buildings constructions projects in ACC. It is recommended that the government should employ an adequate number of building construction engineers, quality assurance officers, as well as project monitoring and evaluations officers who are expected to be tasked to ensure that projects are designed adequately, and their execution are managed and monitored effectively. Also, the government should avail adequate budget for all public building construction works and should pay interim certificates timely to avoid delaying the projects. In addition, the government should formulate and institute a general guideline that obstructs politician and government officers to be bid for public building construction works in their respective councils. This measure is expected to prevent conflict of interest among politicians and government officers.

Abstract TMP42: 911 Continuation Of Care Protocol Reduces Door In, Door Out Time For Transfer Patients With Emergent Large Vessel Occlusion

Background: Rapid reperfusion with mechanical thrombectomy (MT) for large vessel occlusion leads to an improvement functional independence. Prolonged transfers from non-interventional to interventional hospitals are a major cause of delay in reperfusion times. The use of the 911 EMS system has accelerated myocardial infarction transfers and potentially could accelerate stroke transfers, but their effect on stroke transfer times have not been well delineated. Methods: In our 14- hospital system, transfers from non-interventional facilities to intrasystem or intersystem interventional capable facilities typically utilize a centralized group of nurses who arrange for contracted ambulance pickup (CAP). However, in San Bernardino County (CA), 911 EMS continuation of care (COC) is an alternative method available for transferring MT patients. Under the COC process, the sending hospital calls 911 and the nearest EMS ambulance responds to transport the patient to the thrombectomy center. We compared Door In, Door Out (DIDO) times between the COC vs CAP protocol between January 1, 2021 and January 30, 2022. Demographic and clinical variables were compared using t-test for continuous variables and chi-square for categorical variables. Results: Among 112 patients, 26 (23%) were transferred by COC and 86 (77%) by CAP. COC and CAP patients did not significantly differ in age ( Mdn 71 {IQR:22} vs Mdn 72 {IQR:20.5}, p = 0.81), sex (46% vs 36% female, p = 0.92), or presenting NIHSS ( Mdn 14 {IQR:12} vs Mdn 13 {IQR:14}, p = 0.62). Rates of thrombolytic started at the sending hospital were 54% (14/26) in COC patients and 48% (41/86) in ETAP patients (p = 0.58). DIDO time was faster in the COC group, ( Mdn 58 minutes {IQR 44-73} vs Mdn 94 minutes {IQR 79-142}, p&lt;0.01). In contrast, there was a significant difference in DIDO time between intrasystem transfers by COC ( Mdn 69.5 min. {IQR: 48.5-115.5} and transfers out of system by COC ( Mdn 66 min.{IQR: 53-88}, p=0.20), suggesting that there was no special advantage for intrasystem transfers over intersystem transfers. Conclusion: Using the 911 EMS system for interfacility transport of patients eligible for MT reduced DIDO time at the sending hospital by over 40 minutes, which may contribute to improved functional outcome.

Exploring Causes of Delays in National Road and Highway Projects in Developing Construction Economy

Delay in construction projects, especially in road and highway projects, is a universal phenomenon. Afghanistan construction industry is no exception. There are factors causing delays in the Afghanistan construction industry which have negative effects on the key project stakeholders and the project’s deliverables and outcomes. This research aims to identify the causes of delays that affect highway and road projects in Afghanistan and to provide recommendations in order to minimize or control delays in such projects. This will help, in return, facilitate and improve the delivery of roads and highways projects in Afghanistan. To achieve this aim, the study sets out to achieve the following objectives: 1) to determine the most important causes of delay that affect road and highway projects in Afghanistan, 2) to identify the severity of the delay causes from clients’ and contractors’ perspectives, 3) to investigate the differences and discrepancies between clients’ and contractors’ opinions and views, and based on first three objectives, 4) to finally provide recommendations for minimizing and/or controlling delays in road and highway projects, to improve the status-quo and to facilitate procurement/delivery of road and highway projects in Afghanistan. Causes of delay were gathered upon conducting a critical literature review of different types of construction, in different countries. An expert interview and a questionnaire survey formed the basis of this paper, listing 29 important causes of delay in such projects. The major causes of delay then were categorized into three groups following main stages of the highway projects, namely: 1) preparation, 2) procurement, and 3) implementation. The questionnaire survey was distributed to 100 construction participants and 79 were received who represent the government in road projects and contractors. Relative importance index (RII) was calculated and according to the highest values the top ten delay causes of road projects in Afghanistan were determined. Spearman correlation index was used to assess the correlation of causes and groups between clients and contractors. The findings of the study revealed that the top 10 significant factors causing a delay in road projects in Afghanistan are; security (war, theft, kidnapping, etc.), shortage of equipment and material or financial status of contractors, land acquisition, corruption in the procurement process, progress payment delays by owners/clients, non-consideration of security risks in the procurement process, Inaccurate design and bills of quantities, insufficient contractors’ experience, poor qualification of the contractors’ technical staff and award project to lowest bids. The findings will help clients and contractors to mitigate or prevent delays in road and highway projects in Afghanistan. Finally, to help overcome delays in road and highway projects more effectively, recommendations have been made for fundamental reforms in procurement systems for major projects.

Stakeholders’ Insight on the Delay of Constructions Projects in the Makkah Region- KSA

Aims: This study aims to identify the major causes of delays in construction projects in the Makkah region of Saudi Arabia. It investigates the opinions of different stakeholders separately to ensure partiality and objectivity. Background: Saudi Arabia's construction industry is experiencing rapid expansion, with no shortage of contracts in any sector, either from housing or utilities to transport infrastructure. Public spending is driving the contracting industry forward [Oxford]. The construction industry contributed between 30% to 40% of the non-oil productive sectors at the end of each National Development Plan from 1980 to 2000. Makkah receives around two million pilgrims during the annual Hajj and more than 20 million visitors for performing Umrah (Al-Emad). Substantial public funds have been spent on construction projects to develop Makkah during recent years. Real estate, infrastructure, hospitals, and retail sectors are among those most likely to benefit. Most of these projects suffered delays and their consequences. The Saudi Ministry of Municipal and Rural Affairs (MOMRA) and the Ministry of Transportation acknowledged public construction project delays. They reported that approximately 75% of them exceeded their scheduled time. This is one of the main reasons to conduct this study. Methods: In this study, a comprehensive questionnaire has been developed, consisting of seventy-three causes of delay. The questionnaire was organized in the form of an importance scale. Respondents were asked to indicate their responses by ticking a column of the impact and frequency of each of the causes and construction delay in terms of 5 = very important, 4 = important, 3 = somewhat important, 2 = less important, and 1 = not important. A hundred fifty questionnaires were distributed by hand to the contractor, the consultant, and the owner in the Makkah region of Saudi Arabia. Ninety-seven forms were filled, received, and processed. The survey data were grouped into eight significant categories: owner, consultant designer, supervisor, contractor, material, labor, site, and external factors. A ninth group is left for the participants to add whatever they think of furtherer causes of delay. Results: The evaluation of the three separate surveys conducted on the responses of the owner, the contractors, and the consultant supervisor, show that the contractor is mainly responsible for the delay. Around 47% of the top ten delay factors fall in the contractor delay factors followed by laborers and owners. Three categories have not been mentioned in the top ten as delay category, including supervisors, materials, and external factors. Only one delay factor was found to be shared among the three-survey group, which is related to the labor category, that is, low productivity of labor. Conclusion: Three separate surveys have been conducted to investigate the delay in the construction industry in the Makkah region of Saudi Arabia. The surveys contain a questionnaire of seventy-three possible delay factors investigating the opinions of the three main stakeholders in the construction industry: the owners, the contractors, and the consultants. The evaluation of the survey impacts shows that the contractor is mainly responsible for the delay, followed by laborers and then the owners. One common delay factor was found among the three surveyed groups related to the labor category; that is, low productivity of labor. In frequency, the contractor category also occupied the highest percentage of the total delay contributors. Another common delay factor was found among the three surveyed groups, also related to the contractor category, that being the lack of risk evaluation by the contractor.

Automatic Surgical Instrument Recognition—A Case of Comparison Study between the Faster R-CNN, Mask R-CNN, and Single-Shot Multi-Box Detectors

In various studies, problems with surgical instruments in the operating room are usually one of the major causes of delays and errors. It would be of great help, in surgery, to quickly and automatically identify and keep count of the surgical instruments in the operating room using only video information. In this study, the recognition rate of fourteen surgical instruments is studied using the Faster R-CNN, Mask R-CNN, and Single Shot Multi-Box Detectors, which are three deep learning networks in recent studies that exhibited near real-time object detection and identification performance. In our experimental studies using screen captures of real surgery video clips for training and testing, this study found that that acceptable accuracy and speed tradeoffs can be achieved by the Mask R-CNN classifier, which exhibited an overall average precision of 98.94% for all the instruments.

Exploring the significant factors that influence delays in construction projects in Hargeisa

Over the past decades, construction delays have been perceived as a global challenge that hinders the time delivery, budget, and quality of construction projects. It is the most common, expensive, and risky problem associated with both private and public construction projects. Within this context, the aim of this study is to investigate the significant factors that influence delays in construction projects in Hargeisa, using the road and building projects as a baseline. Through a questionnaire survey with 51 critical delay factors that are categorized into seven major groups, data were collected from 51 construction stakeholders selected based on simple random sampling from the different construction companies. Feedback from the respondents was analyzed using Relative Importance Index (RII) for ranking purposes. Results showed that delay in honoring payment progressively, underestimation or overestimation of the project cost, and delay in the approval of major changes in the work scope were ranked as the three major causes of delays in construction projects in Hargeisa. The implications of these results are vital to future projects as they clearly demonstrate how less attention is given to the application of project management tools such as robust cost, scope and risk management in construction projects. As such, construction stakeholders are recommended to make efforts to use the appropriate project management practices needed to manage the 16 identified critical delay factors, when executing future construction projects. Although, the current study focused on Somaliland construction projects, it expands and improves the understanding of delay factors in the global context, and as such can be applied to other countries and future studies.

WITHDRAWN: Operational maintenance analysis of actively utilized road construction equipments

Equipment are the integral part of construction industry and plays vital role in performance of construction works, so the research aims to analyze the operational maintenance of actively utilized road construction equipment of “A” class construction company in Kathmandu, Nepal. The study considers 50 Numbers. of operators for questionnaire and 5 Key Informant Interview from each company for reckoning the Equipment Availability, Equipment Utilization Scheduled Compliance, Maintenance Ratio, Mean Time Between Failure, Reliability, Maintainability. The equipment utilization trend of companies had been increased within optimum utilization. The equipments seem very old crossing their economic life span. The maintenance strategy adopted was breakdown type. Scheduling of equipment operation was affected by instant breakdown of equipments due to lack of backup equipments at workshop and operators shortages. Equipment needs maintenance after utilization of 94 h less than standard practice of 100 h. Average equipment availability is 0.91 against standard of minimum 0.95. Major cause of delay in maintenance of equipments was the delay in receiving spare parts of breakdown of the equipments. Routine spare parts like filters, belts, nut bolts, teeth, cutting edge are easily available while for the sophisticated and typical spare parts need to be imported normally takes 15 to 30 days to deliver. The improper management of the equipment shows cause of unreliability of equipment.

Association and Determinants of Decision-Delivery Interval of Emergency Caesarean Sections and Perinatal Outcome in a Tertiary Institution

Introduction: A Decision to Delivery Interval (DDI) of 30 minutes for emergency caesarean section has been widely recommended but there is little evidence to support it. This target may not be practicable in a busy maternity unity and therefore, the anticipated beneficial effect on neonatal outcome requires re-evaluation. Aim: To determine the association between decision-delivery interval and perinatal outcome of emergency caesarean section at Alex Ekwueme Federal University Teaching Hospital, Abakaliki (AEFUTHA) over a period of four years. Materials and Methods: This was a retrospective observational study of the cases in emergency caesarean sections performed at the Department of Obstetrics and Gynaecology, AEFUTHA from 1st January 2012 to 1st January 2016. Hospital records of the women with singleton pregnancy at term who delivered through emergency caesarean sections were retrieved. Data extracted include socio-demographic and obstetric characteristics, duration between decision for caesarean section and intervention, indications for the caesarean section, reasons for delay in DDI, association between booking status and DDI and association of DDI and foetal outcome, APGAR score at 1st and 5th minutes and admission to NICU. Data were analysed with IBM statistics version 20. The p-value &lt;0.05 were regarded as statistically significant. Results: A total of 638 emergency caesarean sections involving singleton pregnancies at term, 522 (81.8%) of which had complete records and were analysed. The mean age of participants was 27.8±5.1 years, 89.3% were para 1-4 and 55.0% were unbooked. Only 6 (1.1%) of the emergency caesarean sections were performed within the recommended 30 minutes of DDI. The mean DDI was 189±124 minutes with range of 25 minutes to 1220 minutes. Two cases performed within 25 minutes were cases of foetal distress and cord prolapse while only a case of reduced foetal movement was delayed to 1220 minutes. The most common indications for emergency caesarean section were cephalopelvic disproportion 129 (24.7%) and foetal distress 65 (12.5%). The major cause of delay was delay in cross-matching of blood for surgery 136 (26.1%) while delay in giving informed consent contributed 67 (12.8%). There was no correlation between DDI of 75 minutes or above and the 1st minute APGAR score (AOR=2.48, CI=0.86-7.16, p-value=0.09), 5th minute APGAR score (AOR=3.08, CI=1.55-6.11, p-value=0.09), foetal outcome (AOR=0.82, CI=017-3.79, p-value=0.08) and admission to Newborn Intensive Care Unit (NICU) (AOR=2.08, CI=0.77-5.56, p-value=0.14). Conclusion: This study showed that there was no correlation between DDI&gt;75 minutes and poor perinatal outcome. Efforts should be made to strengthen the health system and improve the quality of care in order to keep DDI within this time limit for improved perinatal health outcome and indices.

A Framework of Software Project Scope Definition Elements: An ISM-DEMATEL Approach

Software project scope definition is complicated due to the diversity and magnitude of the information needed. An inadequate scope definition often results in project failure as it continues to emerge as the major cause of delays, changes/rework, and cost and schedule overruns. Literature mentions different tools and methods to verify, quantify, and control software scope definition. However, none of these methods and tools help in defining a complete scope. Since a well-defined scope in the early stages is a core ingredient for project success, therefore, previously we developed a method that includes 45 elements of the software project scope definition. Although these elements are noteworthy for project scope, some may influence others; and should be concentrated on more when defining the scope of the software projects. The objective of this present study is that it builds on our previous research and uses Interpretive Structural Modeling (ISM) to extract the interrelationships among the elements and Decision Making Trial and Evaluation Laboratory (DEMATEL) to determine the intensity of these relationships. Experts from academia and the software development industry were consulted to identify the relationships among the elements. ISM-DEMATEL approach indicates that the project manager's competence is the main driver. Further, requirements, stakeholders' expectations, cost estimates, project schedule, resource estimation, project summary, communication, consultation, top management support are among the most influential elements that are critical to focus on. Moreover, the findings of the study provide project managers with a better understanding of the elements and their interconnections thus, helping in achieving a better scope definition.

Understanding factors of ambulance delay and crash to enhance ambulance efficiency: an integrative literature review

Trauma is one of the major causes of deaths worldwide. The referral time of trauma patients to the trauma center is a vital determinant of traumatic injury patients’ survival. Ambulance delays and crashes are the major causes of delay of patient transportation to the hospital. This review was conducted to find the main factors that cause ambulance crashes and ambulance delays; and discuss the correlation of both factors. Hence, the authors might suggest an appropriate solution to minimize ambulance delay and crash incidents. This integrative literature review applied the PRISMA-P protocol to ensure a robust literature search. A total of nine databases and publishers (i.e., PubMed, Scopus, ScienceDirect, ASCE Library, Clinical Key, EBSCO, Cambridge, Taylor &amp; Francis, and ProQuest) were searched using relevant keywords to obtain studies on ambulance delays and ambulance crashes. The literature search retrieved 620 studies to be screened based on the exclusion-inclusion criteria which finally resulted in the 12 studies included in the review. The researchers conducted a risk of bias assessment using Joanna Briggs Institute's critical appraisal tools. Data from the included studies were then extracted and analyzed using descriptive statistics to identify the factors affecting ambulance delays and crashes. After conducting an integrative literature review, the main factor that causes ambulance delays is traffic congestion. Meanwhile, the main factor causing ambulance crashes is intersection. Traffic congestion often occurs especially at intersections. The authors concluded that, intersections have a significant effect on ambulance delays and also ambulance crashes. To overcome this problem, the authors suggest to make an additional ambulance caution signal lamp on all congested intersections.

The Clinical Need for New Diagnostics in the Identification and Management of Patients with Suspected Sepsis in UK NHS Hospitals: A Survey of Healthcare Professionals.

Development of a new diagnostic is ideally driven by an understanding of the clinical need that the test addresses and the optimal role the test will have within a care pathway. This survey aimed to understand the clinical need for new sepsis diagnostics and to identify specific clinical scenarios that could be improved by testing. An electronic, cross-sectional survey was circulated to UK National Health Service (NHS) doctors and nurses who care for patients with suspected sepsis in hospitals. Two hundred and sixty-five participants completed the survey, representing 64 NHS Trusts in England. Sixty-seven percent of respondents suggested that the major cause of delay was during the initial identification of sepsis and the subsequent recognition of patients who were deteriorating. Existing blood tests did not enhance the confidence of consultants making their diagnoses. Those surveyed identified a role for a near-patient test to “rule out” suspected sepsis and, thereby, stop or postpone use of antibiotics. Current diagnostic tests are slow, non-specific, and do not reliably identify patients with a high suspicion of sepsis. As a result, they have a limited use in patient management and antibiotic stewardship. Future development of sepsis diagnostics should focus on overcoming these limitations.

S1232 Patient Tardiness, Physician Tardiness, and Procedural Nurse Pre-Operative Workflow Drive Delays in the First and Second Procedure Start Times in a Tertiary Care Endoscopy Unit

INTRODUCTION: As demand for endoscopy increases, there is a greater need for efficiency in endoscopy facilities. This study aims to identify workflow bottlenecks at a high-volume tertiary care center endoscopy unit at the beginning of the workday. METHODS: We mapped hospital staff workflow from the time of patient arrival to our facility to the start of their endoscopic procedure. We quantified delays to the start of the first case of the day for inpatient and outpatient endoscopy procedures from May 1, 2019 to January 31, 2020 and categorized the reasons for delay through our electronic medical record (Epic). Delays were defined as cases that started greater than 5 minutes after scheduled time. Turnaround time, defined as the period between the end of the first case to the start of the second case, was also quantified through data in our electronic medical record. RESULTS: Of the 599 first cases, 85% of inpatient (n = 25) and 73% of outpatient (n = 574) cases did not start on time. Approximately 10% of inpatient cases rolled over to the next day. The most common causes of delays in the start of the first case were patient tardiness (44%, n = 147) and GI physician tardiness (36%, n = 108) (Figure 1), translating to a mean of 35 minutes and 22 minutes of delay respectively. Within our standard workflow, the mean pre-operative time was 67 minutes. The median registration time was 17 minutes. The median total pre-operative documentation time was 50 minutes, of which 27 minutes were with nursing, 5 minutes with GI, and 5 minutes with anesthesia (Figure 2). The remaining 13 minutes were spent waiting, during which the patient was not interacting with a health care provider. CONCLUSION: At our high-volume tertiary care center endoscopy unit, more than half of our first cases of the day did not start on time. The most common factors were patient and GI physician tardiness. The pre-operative process was found to be a major cause of delay in starting the second case of the day. There are large gaps in the pre-operative window where the patient is not interacting with a healthcare provider. Further research is needed to measure the effect of planned interventions and reduce delays.Figure 1.: Documented reasons for delay of the first endoscopy case of the day.Figure 2.: Median and interquartile ranges of pre-operative times by procedural nurse, GI provider, and anesthesia provider for preparation of first and second patients of the day.

Role of topical use of natural honey in chronic non healing ulcer: a prospective non randomized comparative trial on 150 patients

Background: Natural honey procured from any source on topical application on chronic non-healing ulcer has unique property to reduce pain, inflammation, oedema, deodorization, rapid disinfection, stimulate desloughing, promote neo vascularization, granulation, collagen synthesis, epithelialization and thus boost the process of ulcer healing.Methods: In this study a prospective, non-randomized trial was done on 150 patients divided in two groups of 75 each (group-A with honey dressing and group-B without honey dressing), of different age and sex having chronic non healing ulcers situated on various parts of the body. Natural honey available from various sources was used.Results: Most of the patients fall in their most productive and active 3rd and 4th decade of life. Pain and fever were the main reason of restricted mobility and absence from work reflecting productivity. Bacterial contamination, presence of necrotic tissue, bed ridden condition, old age, debility, DM, ulcer present in the vicinity of joint were found major cause of delay in the process of healing. The cost effectiveness, easy availability, ease of application makes natural honey a better alternative in the management of chronic non healing ulcer.Conclusions: Cost effectiveness, easy availability, ease of application, increasing healing process makes natural honey a better alternative in the management of chronic non healing ulcer and safe to use in diabetic patients as well.