Multidisciplinary Case Review Research Articles

Leveraging the Fetal and Infant Mortality Review (FIMR) Process to Advance Health Equity.

The fetal and infant mortality review (FIMR) process is a community-oriented strategy focused on improving the health services systems for pregnant persons, infants, and their families. FIMR helps communities to understand and change systems that contribute to racial disparities in birth outcomes. FIMR equally values the medical and social services delivery records and the personal narratives of families who have suffered a fetal or infant loss when creating the de-identified case summaries to be reviewed by teams. A two-tiered process, FIMR uses a multidisciplinary Case Review Team (CRT) as the information processor and the Community Action Team (CAT) as the action arm of the process. Pediatricians are vital to both teams, helping to bring about systems change to improve maternal and child health. This paper examines how the well-established FIMR team serving Indianapolis (Marion County, IN) worked to build the capacity of its CAT to address racial disparities in birth outcomes through 5 distinct steps: focus on the primary causes of local fetal or infant mortality, focus on neighborhoods with the highest stable fetal or infant mortality rates, designation of a CAT leader, creation of a culture of regular CAT meetings inclusive of a health-equity skill building curriculum, and inclusion of Grassroots Maternal and Child Health Leaders on the CAT. This paper demonstrates how the synergy between local organizations and community members can effectively address racial disparities in birth outcomes.

Reappraising imaging features of pancreatic acinar cystic transformation: be aware of differential diagnoses.

Imaging features of pancreatic acinar cystic transformation (ACT) have been published. We aimed to describe the clinical and radiological characteristics of patients with a presumed pancreatic ACT diagnosis, reappraising the value of these published imaging criteria. Single-center retrospective study (2003-2021) of consecutive patients with a presumed diagnosis of ACT as suggested by the local expert multidisciplinary case review board. Patients without available imaging (CT or MRI) for review were excluded. Patients were classified into "certain" ACT (if ≥ 2 imaging criteria and no differential diagnosis) or "uncertain" ACT (if ≥ 1 imaging criteria and suggested differential diagnoses). Sixty-four patients (35 males, [55%]) were included. ACT was considered "certain" for 34 patients (53%) and "uncertain" for 30 patients (47%). The number of ACT criteria did not differ between groups, with 91.2% of patients with ≥ 3 ACT imaging criteria in the "certain" group vs 93.3% in the "uncertain" group (p = 0.88). In the "uncertain" group, the main suggested differentials were branch-duct intraductal papillary mucinous neoplasm (18/30 patients, 60%), calcifying chronic pancreatitis (8/30 patients, 27%), both (three patients, 10%) and serous cystadenoma (one patient, 3%). Calcifications were significantly more frequent in the "uncertain" group (89% vs 63% in the "certain" group, p = 0.02). Published ACT imaging criteria are frequently associated with features suggesting differential diagnoses. They appear insufficient to reach a final diagnosis in a subset of patients. ACT displays a heterogeneous morphological imaging presentation challenging the non-invasive diagnostic work-up. Physicians' and radiologists' awareness of this entity is important to better understand its natural history and improve non-invasive diagnostic criteria. The criteria to help diagnose ACT are frequently associated with features suggestive of differentials. The main alternatives suggested when ACT diagnosis was "uncertain" were branch-duct intraductal papillary mucinous neoplasm and calcifying chronic pancreatitis. Published ACT diagnostic imaging criteria can be insufficient for a definite non-invasive diagnosis.

Advancing the Clinical and Molecular Understanding of Cornelia de Lange Syndrome: A Multidisciplinary Pediatric Case Series and Review of the Literature.

Cornelia de Lange syndrome (CdLS) is a complex genetic disorder with distinct facial features, growth limitations, and limb anomalies. Its broad clinical spectrum presents significant challenges in pediatric diagnosis and management. Due to cohesin complex mutations, the disorder's variable presentation requires extensive research to refine care and improve outcomes. This article provides a case series review of pediatric CdLS patients alongside a comprehensive literature review, exploring clinical variability and the relationship between genotypic changes and phenotypic outcomes. It also discusses the evolution of diagnostic and therapeutic techniques, emphasizing innovations in genetic testing, including detecting mosaicism and novel genetic variations. The aim is to synthesize case studies with current research to advance our understanding of CdLS and the effectiveness of management strategies in pediatric healthcare. This work highlights the need for an integrated, evidence-based approach to diagnosis and treatment. It aims to fill existing research gaps and advocate for holistic care protocols and tailored treatment plans for CdLS patients, ultimately improving their quality of life.

Implementation of a Severe Maternal Morbidity Quality Review Process at a Level IV Public Hospital [ID: 1377992

INTRODUCTION: Severe maternal morbidity (SMM) is tracked by national organizations offering opportunities to evaluate, monitor, and address in near real time. Using a multidisciplinary case review committee to analyze all cases of SMM at a level IV inner-city hospital, we hypothesized that case reviews will identify opportunities for improvement in obstetric practices. METHODS: A case review was triggered for any delivery with an SMM ICD-10 code, transfusion of greater than 4 units, readmission within 48 hours of discharge, a patient safety concern by staff, or a severe adverse neonatal outcome. This cohort study included all of the case reviews of cases between 2019 and 2022. Severe maternal morbidity outcomes, demographics, and obstetric practices were analyzed. RESULTS: Of 36,671 deliveries, 296 (0.8%) met criteria and were reviewed. Of these, 80 (27%) had two or more concurrent SMM events. Postpartum hemorrhage was the most common (37%), followed by intensive care unit admission (13%) and hysterectomy (12%). After review, practices done well included interdisciplinary communication and prompt decision-making. Opportunities for improvement included inadequate access to peripartum care due to socioeconomic barriers, communication, and lack of role clarity. CONCLUSION: Social barriers, inadequate communication, and lack of role clarity were identified as the most common areas of improvement in SMM cases. These findings led to the development of an escalation of care pathway for massive transfusion protocol and vital signs thresholds at which to contact anesthesia. The implementation of a standardized SMM surveillance system results in systematic improvements in obstetric practices.

Abstract WP34: Collaboration Between Acute Care Hospitals And Rehabilitation Hospitals Reduces 30-day Readmission And Mortality After Ischemic Stroke Hospital Discharge

Background: To improve transitions of care from an acute hospital to an acute rehabilitation hospital, monthly multidisciplinary case review meetings among these hospitals' staff were implemented in 2020. This study aimed to determine whether this effort improved the outcomes of stroke patients. Methods: Monthly online meetings among the acute stroke care team and 3 rehabilitation hospital team leaders were implemented in a large healthcare system. The goal of these meetings was to review all readmissions in-depth, promote communication, and establish best practice protocols to reduce adverse events. We compared patient outcomes before (2018-2019, n=360) and after (2020-2021, n=264) the intervention using multivariate logistic regression models. The primary outcomes were all-cause mortality and readmission within 30 days after acute hospital discharge. Secondary outcomes were 30-day mortality, readmission, and ED visits. The models were adjusted for patient demographics, comorbidities, stroke severity assessed with the National Institute of Health Stroke Scale (NIHSS), and hospital stroke certification status. Results: The median patient age was 70 (interquartile range [IQR]: 60;79), and 297 (48%) were females. The patients in the post-intervention period had longer hospital stays (median 6 vs. 5 days, p<.0001) and higher median NIHSS scores (6 vs. 4, p=0.03). The intervention was associated with lower 30-day all-cause mortality and readmission (12% vs. 22%, Adjusted odds ratio [aOR], 0.562; 95% confidence interval [CI], 0.344-0.920). Readmissions alone were reduced (11% vs. 22%, aOR, 0.557; 95% CI, 0.338-0.918). No significant associations between the intervention and mortality (aOR, 1.00; 95% CI, 0.21-4.85) or ED visits (aOR, 0.86; 95% CI, 0.52-1.40) were found. Conclusion: The multidisciplinary case review meetings among neurology and rehabilitation staff may greatly reduce 30-day hospital readmissions and mortality after acute stroke hospital discharge.

Evaluating the resource implications of different service delivery models for offering additional genomic findings

To evaluate the resource implications of different delivery models for the provision of additional findings (AF) in genomics from a health-care purchaser perspective. Data from the Additional Findings study were used to develop and validate a discrete event simulation model that represented the pathway of delivering AF. Resource implications were estimated by microcosting the consultations, sample verifications, bioinformatics, curation, and multidisciplinary case review meetings. A proof-of-concept model was used to generate costing, and then the simulation model was varied to assess the impact of an automated analysis pipeline, use of telehealth consultation, full automation with electronic decision support, and prioritizing case review for cases with pathogenic variants. For the proof-of-concept delivery model, the average total cost to report AF was US$430 per patient irrespective of result pathogenicity (95% confidence interval [CI] US$375-US$489). However, the cost of per AF diagnosis was US$4349 (95% CI US$3794-US$4953). Alternative approaches to genetic counseling (telehealth, decision support materials) and to multidisciplinary case review (pathogenic AF cases only) lowered the total per patient cost of AF analysis and reporting by 41-51%. Resources required to provide AF can be reduced substantially by implementing alternative approaches to counseling and multidisciplinary case review.

An Interdisciplinary Team Decreases Hospital Acquired Infections in HCT Patients

Topic Significance & Study Purpose/Background/Rationale Prevention of healthcare-associated infections (HAI) is a priority of regulatory and national agencies and CMS implemented payment reductions for HAIs as of 2015. Central Line Associated Blood Stream Infections (CLABSI) in hospitalized patients are challenging HAIs that are known to increase lengths of stay, financial burdens, and overall mortality. HAI definitions are based on non-immunocompromised patient populations and immunocompromised patients often have increased reporting for these infections. Our NCCN hospital sought to better describe CLABSIs in our hematopoietic cell transplant (HCT) population to assure appropriate reporting of HAIs and to identify opportunities for quality improvement. Methods, Intervention, & Analysis An interdisciplinary team including the Infection Prevention Medical Director, Infection Preventionists and Physicians, Pharmacist, inpatient Nurse Manager and a Clinical Nurse Specialist met monthly to perform intensive reviews of CLABSI events that occurred on an inpatient HCT unit. The review included patient risk factors for infection and the degree to which nurses followed the central line care bundle. As a result of these reviews, a Staff RN group was formed who were educated to became unit experts on CLABSI and central line care. Subsequently, CLABSI rates reduced by 30%. Findings & Interpretation CLABSI reviews found common organisms across cases, opportunities for improvement in nursing practice as well as trends in patient characteristics where gaps in care may exist. By expanding these reviews to other HAIs, situations where standard definitions may not directly apply were identified, particularly with Clostridium Difficile Infection (CDI). The interdisciplinary CDI review focused on common causes of diarrhea which were then categorized and shared with staff to aid in patient care decisions. Discussion & Implications Intensive review of HAI events and identification of trends in the immunocompromised patient population assures accurate reporting of these cases. Reviews also allow for development of internal classifications of causes and ongoing process improvement in patient care by identifying unique situations leading to those infections. While this process requires resources to perform data collection and to review cases, the subsequent potential improvement in patient care may offset those. Multidisciplinary case review can help to improve practice, decrease infections, and potentially decrease the cost of patient care.

A Qualitative Study Examining Stakeholder Perspectives of a Local Child Abuse Program in Community Emergency Departments

ObjectiveEmergency department (ED) providers may fail to recognize or report child abuse and/or neglect (CAN). To improve recognition and reporting, we designed the Community ED CAN Program, in which teams of local clinicians (nurses, physicians, physician assistants) received training in CAN and 1) disseminated evidence-based education; 2) provided consultation, case follow-up, and access to specialists; and 3) facilitated multidisciplinary case review. The aims of this study were to understand the Program's strengths andchallenges and to explore factors that influenced implementation. MethodsWe used a qualitative research design with semistructured, one-on-one interviews to understand key stakeholders' perspectives of the Community ED CAN Program. We interviewed 27 stakeholders at 3 community hospitals and 1 academic medical center. Researchers analyzed transcribed data using constant comparative method of grounded theory and developed themes. ResultsProgram strengths included 1) comfort in seeking help from local champions, 2) access to CAN experts, 3) increased CAN education/awareness, and 4) improved networks and communication. Facilitators of implementation included: 1) leadership support, 2) engaged local champions and external change agents (eg, CAN experts), 3) positive attributes of the champions, and 4) implementation flexibility. Program challenges/barriers to implementation included 1) variability of institutional support for the champions and 2) variability in awareness about the program. ConclusionsA Community ED CAN Program has the potential to improve recognition and reporting of CAN. Key steps to facilitate implementation include the identification of committed local champions, strong leadership support, connections to experts, program publicity, and support of the champions' time.

349: System improvements associated with reduced time-to-treatment for maternal hypertension in a statewide quality improvement Initiative

The Illinois Perinatal Quality Collaborative (ILPQC)’s Maternal Hypertension (HTN) initiative increased the percentage of new onset severe HTN (BP ≥160/110) cases treated within 60 minutes from 41.5% to 85.0% at 110 hospitals through collaborative learning, rapid-response data, and quality improvement (QI) support. We aim to identify which hospital system improvements facilitated by the initiative were associated with reduced time to treatment (T2T) given the importance of T2T in severe maternal morbidity and mortality associated with severe maternal HTN. Participating hospitals reported T2T for all cases of severe maternal HTN during the QI initiative (April 2016-December 2017). Status of key system improvements were reported quarterly. A mixed effects generalized linear model was used to estimate the association between achievement of system improvements and T2T. Odds ratios were adjusted for hospital characteristics: birth volume, location (urban / rural), and patient mix (race and Medicaid status) in 2014. Hospitals that created standard protocols for early warning signs, diagnostic criteria, monitoring, and treatment had 1.43 the odds of treating a severe maternal HTN case in <60 minutes, compared with hospitals that did not (p=0.02). Unit education of providers and nurses (aOR: 1.37, p=0.01), rapid access to IV antihypertensive medications on antepartum/postpartum floors (aOR: 1.45, p=0.02), and multidisciplinary reviews (aOR: 1.40, p=0.02) were also associated with improved efficacy in reducing T2T of severe maternal HTN (Table 1). Implementation of four hospital system improvements (protocols for management of severe maternal HTN, unit education, rapid access to antihypertensive medications, and multidisciplinary case reviews) were significantly associated with reduced T2T of severe maternal HTN, regardless of hospital characteristics. Further investigation into the overall effect of other system improvements will clarify their role in reducing T2T. Identifying key hospital system improvements can inform future perinatal quality collaboratives and hospital-level QI initiatives to reduce T2T and improve outcomes for pregnant and postpartum women with severe HTN.

The Employers Centers of Excellence in Cancer Care: A collaboration of employers and providers to improve cancer care.

141 Background: Rising costs demand collaborations that lower expenditures and improve patients’ experiences and outcomes. We created a novel employer-provider collaboration to enhance value-based cancer care. Methods: We created an Employers Center of Excellence Network (ECEN) for the Pacific Business Group on Health (PBGH) employee groups. The ECEN provides competitive bundled rates that include travel for in-person patient consultation, advanced assessment and treatment by multidisciplinary case reviews, and ongoing specialized treatment care coordination and follow-up on a routine basis with the local care team.The ECEN development process included: focus groups, expert panel development, and a rigorous selection process. A Request for Proposal was publicized to all west coast NCI-designated comprehensive cancer centers. After interviews, selected sites were invited to submit a full proposal and a few were selected for a site visit.. In addition to overall cancer care excellence, a key criterion for acceptance was the demonstrated willingness and ability of the center to provide long-term support for the patient and home oncologist in the patient’s home market, so that the center’s expertise and support would be ongoing for the duration of the cancer treatment. Results: Of 8 sites that participated in team-assessment interviews, 4 were selected to submit a full proposal, 3 selected for in-person visits, and 1 selected to participate. In January 2019, we plan to implement a 6-month pilot with a PBGH employer group and the provider site to evaluate the ECEN's feasibility and effects on quality, patient-reported outcomes, and costs. Conclusions: Our novel employer-provider collaboration aims to improve cancer care delivery by providing planned and supported NCI-designated cancer care in close collaboration with the home oncologist. We plan to expand the ECEN development process across the US to develop a network of collaborating providers and employers to improve patient-centered, value-based cancer care.

Timely treatment of severe maternal hypertension and reduction in severe maternal morbidity.

To determine if timely treatment within 60 min of confirmed diagnosis of severe maternal hypertension with antihypertensive medications was associated with reduction in severe maternal morbidity. Medical records of women with severe hypertension (at least two severe blood pressures, systolic ≥160 mmHg and/or diastolic ≥110 mmHg, within 60 min) were accessed for timing of severe blood pressures, timing of treatment, and blood pressure response to treatment. Severe maternal morbidity was confirmed by multidisciplinary case review. We compared the incidence of severe maternal morbidity between women who received timely (within 60 min of diagnosis) vs. not-timely treatment. Of 465 women with severe hypertension, 29 (6.2%) experienced severe maternal morbidity. Fifty-six percent of women received timely treatment, of whom 1.9% had severe maternal morbidity, compared with 6.4% of women who did not receive timely treatment (p = 0.02). Timely treatment was associated with a 72% reduction in relative risk of severe maternal morbidity (p = 0.02). No significant difference was seen in median pre-treatment systolic pressures (p = 0.20) between the groups. Antihypertensive treatment within 60 min of confirmed diagnosis of severe hypertension was associated with reduction in severe maternal morbidity. Our findings support current recommendations to treat all women with severe hypertension with antihypertensive medications in a timely fashion.

Abstract P-181: MAKING IT BETTER: HEALTH CARE ASSOCIATED INFECTIONS (HCAI) IN CARDIAC INTENSIVE CARE

Aims & Objectives: To establish the incidence and impact of HCAI in children with congenital cardiac diseases requiring paediatric intensive care (PIC). Methods Prospective data collection (January 2013-June 2017) with multidisciplinary case review / thematic analysis of all suspected HCAI’s in children requiring PIC support with a primary cardiac diagnosis, aimed at identifying high risk patients, preventable factors and developing risk reduction strategies. Categories included central line associated blood stream infections (CLABSI), ventilator associated pneumonias (VAP), hospital acquired blood stream infections (HA BSI), surgical site infections (SSI) and catheter associated urinary tract infections (CA-UTI). Comparison was made with non cardiac children treated on PICU during the same time period Results 6259 children were admitted to PIC. 1494 (24%) of these had a primary cardiac diagnosis.The commonest cardiac HCAI’s were SSI’s, followed by CA-UTI and HA-BSI. 53% (n=42) of the cardiac group had single ventricle circulations. 19% had an associated immunodeficiency. CLABSI’s, HA BSI and SSI rates all fell over the study period as a result of thematic analysis and quality improvement initiatives. VAP and CA-UTI remain problematic. Conclusions HCAI in children requiring cardiac intensive care are common and up to 60% may be preventable. Ongoing surveillance and risk reduction strategies can lead to significant improvements in this high risk group.

Testicular Cancer Review Panel: Multidisciplinary specialist review of a rare cancer at Kaiser Permanente, Northern California.

561 Background: Testicular cancer is a rare disease; multidisciplinary management by experienced clinicians is recommended. Methods: Multidisciplinary specialized review of all new testicular cancer cases was established in a community setting by creating a twice monthly Testicular Cancer Review Panel, comprised of two subspecialized medical oncologists and two surgical urologic oncologists, at Kaiser Permanente in Northern California. An early ascertainment list of new testicular cancer diagnoses was obtained and review of the history, labs, pathology reports, and all relevant imaging was performed via a web-based conference. Urologic cancer fellowship trained pathologists and body fellowship trained radiologists were available for secondary review when requested. All recommendations were documented in patient charts. Results: From June 2016 to June 2017, 131 cases were reviewed. Review by the panel resulted in significant changes in care in 19 of 131 patients (14.5%). Pathology and radiology re-reviews were the most common sources of changes in treatment recommendations. Embryonal predominant T1 disease was referred for GU pathology review in 14 cases; in 8, lymphovascular invasion was identified, upstaging 6.1% of patients from 1A to 1B, changing treatment from observation to chemotherapy. Radiology re-review changed the stage and treatment in 11 patients (8.4%), identifying lymphadenopathy not previously noted in 7 patients and reassessing previously identified lymphadenopathy as a non-pathologic finding in 4 patients. The percentage of patients with stage I seminoma observed rather than undergoing adjuvant therapy increased from 11/15 (73.3%) over the first six months of the panel to 18/20 (90%) over the second six months. Convening the panel also resulted in dissemination of oncologic knowledge among treating physicians. Conclusions: Multidisciplinary specialized case review for a rare disease is feasible in the community setting and frequently alters care.

A New Software Platform to Improve Multidisciplinary Tumor Board Workflows and User Satisfaction: A Pilot Study

Background: Workflow and preparation for holding multidisciplinary cancer case reviews (i.e., Tumor Boards) is time-consuming and cumbersome. Use of a software platform might improve this process. This pilot study assessed the impact of a new software platform on tumor board preparation workflow and user satisfaction compared to current methods. Materials and Methods: Using current methods and the NAVIFY Tumor Board Solution, this study assessed the number of tasks and time to prepare tumor board cases. Participants completed online surveys assessing ease of use and satisfaction with current and new platforms. Results: A total of 41 sessions included two surgeons, two oncologists, two pathologists, and two radiologists preparing tumor board cases with 734 tasks were recorded. Overall, there was no difference in the number of tasks using either preparation method (341 current, 393 NAVIFY Tumor Board solution). There was a significant difference in overall preparation time as a function of specialty (F = 71.74, P < 0.0001), with oncologists, radiologists, and surgeons having reduced times with NAVIFY Tumor Board solution compared to the current platform and pathologists having equivalent times. There was a significant difference (F = 38.98, P < 0.0001) for times as a function of task category. Review of clinical course data and other preparation tasks decreased significantly, but pathology and radiology review did not differ significantly. The new platform received higher ratings than the current methods on all survey questions regarding the ease of use and satisfaction. Conclusions: The study supported the hypothesis that the new software platform can improve Tumor Board preparation. Further study is needed to assess the impact of this platform in different hospitals, different data storage systems, with different observers, and different types of Tumor board cases as well as its impact on the quality of the tumor board discussion.

Huntington disease care: From the past to the present, to the future

IntroductionHuntington disease is a progressive neurodegenerative disorder without a cure. Its clinical presentation makes complex the care of patients with HD, further impacted by the progressive loss of dependence and disability. Intuitively, HD management calls for multispecialty care. MethodsLiterature review and expert-based statement. ResultsChorea is the only indication for symptomatic treatments in HD. Surgical therapies are experimental, and exercise-based physical interventions have been assessed but in small feasibility studies. In HD, multispecialty care requires the active involvement of physicians, therapists, social workers and nutritionists. In about half of the HD clinics, a multidisciplinary case review is offered. It is still unknown what is the care delivery model that is best for HD. Palliative care is an important concept in HD care focusing in quality of life, considering physical, psychosocial, and spiritual problems. Palliative care may delay nursing home placement in advanced HD. ConclusionThere is a support for multispecialty care in HD, but more evidence needs to be generated through clinical research. The implementation of technology in the multispecialty care of patients with HD has a significant potential for reducing the care burden for families and the healthcare team, and to secure a wider care delivery.

Injury Prevention and State Law as Strategies for the Reduction of Child Maltreatment Fatalities

This review focuses on one state’s multidisciplinary legislative efforts to decrease the incidence of child maltreatment, including fatalities and near-fatalities. Such efforts have encompassed primary and secondary prevention modalities, including early support to parents, training, and education about recognition and reporting of child maltreatment for professionals who interact with children, review of all child deaths, and multidisciplinary in-depth case review of the most serious child maltreatment cases. Although reliable trends can be difficult to determine based upon the complexity of the problem and multiple confounding variables, there are a number of indicators that suggest these cumulative efforts are beginning to have a favorable impact on the most serious child maltreatment cases, although heightened awareness has likely contributed to an increase in the total number of reported cases. Multidisciplinary collaborative efforts including governmental, academic, and non-profit entities may affect meaningful change in legislation and other interventions to decrease the incidence of the most serious cases of child maltreatment.

Abstract TP367: Decreasing Decision to Transfer Times

Novant Health Greater Charlotte market is comprised of three advanced primary stroke care centers; one providing 24/7 stroke interventional radiology coverage. To expedite the transfer of patients meeting criteria for mechanical thrombectomy, the stroke best practice teams in the two community primary stroke centers collaborated to develop a protocol to improve the decision to transfer time to meet a goal of 120 minutes from door to skin puncture time, regardless of original transport destination. The Novant Health Charlotte market teams realize the benefit of cohesive physician coverage among the Emergency Department, Radiology and Inpatient Neurology physician providers. CTA scans performed in the non-interventional facilities are readily available to Neuro-Endovascular Radiologists, allowing for prompt interpretation and mobilization of the IR team to prepare for patient arrival. Recognizing internal critical care transport resources are limited and may not be available, the process was facilitated by the development of an activase transport protocol implemented by Mecklenburg County EMS in June of 2016. Since actual transport time is affected by traffic patterns in urban areas, the controllable measure selected by the teams was decision to transfer time. Prior to the initiation of the protocol, the median decision to transfer time for ischemic stroke patients requiring tertiary care was 66.5 minutes. Post protocol implementation the median time was reduced 32% to 44.5 minutes. Across the market, median door to skin puncture time in 2016 is 131.5 minutes. Ongoing evaluation of the transfer process, and multidisciplinary IR case review with identification of process variation is key to the success of this initiative. The Emergency Department at the tertiary care facility has been an instrumental partner in identifying issues that are barriers to timely throughput of these patients. A consistent feedback process informs all team members regarding patient outcomes. Individual case feedback is provided to all direct care givers, EMS crews and stroke team leaders, usually within 24 to 48 hours of the intervention. This data is shared monthly with the stroke best practice teams at the transferring facilities.

A Mixed Methods Evaluation of the Northwest London Integrated Care Pilot

The National Health Services (NHS) within inner Northwest London implemented a transformational change pilot program for integrated care from 2011-13. This pilot focused on two populations within the inner northwest quadrant of London: diagnosed diabetics and the elderly over 75 years of age. An information technology (IT) tool was used to pool data across primary, secondary, community, social, and mental health care sectors in order to assess an integrated approach to care coordination. The network of service providers included: 5 social care services; 3 community care services; 106 primary care practices; 2 mental health facilities; 2 hospitals; and 2 non-profit organizations. Some of the main goals of the pilot were to: improve health outcomes among diabetics and the elderly; improve patient experience; reduce service outcomes such as emergency hospital admissions; create care plans for the targeted populations; and establish multidisciplinary case reviews of high-risk patients with the most complex needs. A mixed methods evaluation was essential for assessing the care process and health outcomes of the pilot. Results of the evaluation will be presented, particularly as they relate to clinical outcomes and quality of care, as well as patient and professional experience throughout the integrated care process.

(835) - Lung Transplantation for Systemic Sclerosis: Long-Term Survival, Freedom from BOS and Readmission Rates

Systemic sclerosis (SSc) is often considered a contraindication for lung transplant (LTx) given concerns that extrapulmonary involvement may threaten long-term outcomes. We evaluated key outcomes for subjects undergoing LTx for SSc-related lung disease. We identified all subjects transplanted for SSc and a comparison group of subjects transplanted for idiopathic pulmonary fibrosis (IPF) at UC San Francisco between 11/2002 and 8/2015. Diagnoses were adjudicated by medical record, explant pathology, and, where available, multidisciplinary case review. We compared survival and time-to-bronchiolitis obliterans syndrome (BOS) by Kaplan-Meier methods and multivariate Cox proportional hazard model, adjusted for age, gender, creatinine, transplant type (single vs bilateral), six-minute walk distance, lung allocation score, and ischemic time. We compared 30-day and 1-year readmission rates by Fisher’s exact test. Survival was similar in the 41 subjects with SSc and the 105 subjects with IPF who underwent lung transplant (p=0.19). Estimated survival at 1, 3 and 5 years was 87%, 79%, and 70% for the SSc group and 95%, 84% and 74% for the IPF group (p=0.19) (Figure 1A). Freedom from BOS was similar (p=0.46) (Figure 1B). There was no difference in the multivariate adjusted risk of death (HR = 1.56; 95% CI: 0.49 - 4.95) or BOS (HR=0.32; 95% CI: 0.07-1.58). There was no difference in 30-day (p=1.00) and 1-year (p=0.24) readmission rates which were 9.8% and 12.2% for the SSc group and 11.4% and 21.9% for the IPF group. We found subjects with SSc undergoing LTx had similar survival and freedom from BOS compared to subjects with IPF. Hospital readmission rates were also similar. The extrapulmonary manifestations of SSc do not appear to hinder outcomes after lung transplantation.

Contributory factors and potentially avoidable neonatal encephalopathy associated with perinatal asphyxia

The recently published monograph, Neonatal encephalopathy and neurologic outcome, from the American College of Obstetricians and Gynecologists calls for a root cause analysis to identify components of care that contributed to cases of neonatal encephalopathy to design better practices, surveillance mechanisms, and systems. All cases of infants born in New Zealand with moderate and severe neonatal encephalopathy were reported to the New Zealand Perinatal and Maternal Mortality Review Committee from 2010. A national clinical review of these individual cases has not previously been undertaken. The objective of the study was to undertake a multidisciplinary structured review of all cases of neonatal encephalopathy that arose following the onset of labor in the absence of acute peripartum events in 2010-2011 to determine the frequency of contributory factors, the proportion of potentially avoidable morbidity and mortality and to identify themes for quality improvement. National identification of, and collection of clinical records on, cases of moderate or severe neonatal encephalopathy occurring after the onset of labor in the absence of an acute peripartum event, excluding those with normal gases and Apgar scores at 1 minute, among all cases of moderate and severe neonatal encephalopathy at term in New Zealand in 2010-2011 was undertaken. Cases were included if they had abnormal gases as defined by any of pH of ≤ 7.2, base excess of ≤ -10, or lactate of ≥ 6 or if there were no cord gases, an Apgar score at 1 minute of ≤ 7. A clinical case review was undertaken by a multidisciplinary team using a structured tool to record contributory factors (organization and/or management, personnel, and barriers to access and/or engagement with care), potentially avoidable morbidity and mortality and to identify themes to guide quality improvement. Eighty-three babies fulfilled the inclusion criteria for the review, 56 moderate (67%) and 27 severe (33%), 21 (25%) of whom were deceased prior to hospital discharge. Eighty-four percent of 64 babies with cord gas results had one of pH of ≤ 7.0, base excess of ≤ -12, or lactate of ≥ 6; and 42% (8 of 19) without cord gases had 5 minute Apgar scores < 5. Excluding 5 babies who died within a day of birth, all but 1 baby were admitted to a neonatal unit within 1 day of birth. Contributory factors were identified in 84% of 83 cases, most commonly personnel factors (76%). Fifty-five percent of cases with morbidity or mortality were considered to be potentially avoidable, and 52% of cases were considered potentially avoidable because of personnel factors. The most frequently identified theme related to the use and interpretation of cardiotocography in labor. A multidisciplinary case review of neonatal encephalopathy following apparently uncomplicated labor identified a high rate of potentially avoidable morbidity and mortality and issues amenable to quality improvement such as multidisciplinary training of staff in fetal surveillance in labor.