Patient Arrival Research Articles

Abstract WMP28: Developing a New Hospital Into a Primary Stroke Center in Just Over a Year

Background: Stroke programs are often developed and implemented in well-established health care facilities. There is little data on certified stroke programs being established in new hospitals. Our primary goal was to establish a strong culture of engagement in the care of stroke patients from the day the hospital opened. Methods: A multidisciplinary stroke oversight committee was formed, which guided development of the stroke program and integrated leaders from all areas involved with direct or indirect stroke patient care. We began trending processes and overall stroke care based on the Get with the Guidelines (GWTG) STK measures. In this study we compared data from the opening of a 160-bed hospital until achieving Primary Stroke Center (PSC) certification (October 2021 - February 2023) to after certification (March 2023 - June 2023). Our primary outcome was to examine the proportion of IV thrombolysis prior to and after PSC certification. Secondary outcomes included: proportion of door-to-needle time within 60 minutes, proportion of EMS arrival and proportion of patients transferred prior to and after PSC certification. Primary and secondary outcomes were analyzed using backwards Wald binomial logistic regression models which were adjusted for age, sex and NIHSS. Results: Among 300 patients evaluated for potential stroke symptoms, 228 (76%) were assessed prior to PSC and 72 (24%) after. Mean age was 63.15±17.37 years and median [IQR] NIHSS was 1 [0, 2]. GWTG STK measures were achieved (> 85%) both before and after PSC certification. There was a higher proportion of patients treated with IV thrombolysis after PSC compared to before (9.7% versus 2.6%), adjusted Odds Ratio (aOR) = 3.66 [95% Confidence Interval (CI), 1.17 - 11.43], p = .026. There was no statistical difference in the proportion of IV thrombolysis patients treated within 60 minutes of arrival after versus before PSC, (57% versus 20%), aOR = 5.33 [95%CI, 0.38 - 75.78], p = 0.22. Additionally, there were similar proportions of EMS arrival and transfers after compared to before PSC, all p > .05. Conclusions: A successful stroke program can be implemented in a new hospital within a short duration of time.

Improving emergency department flow by introducing a simple time out moment (The TRAFFIC LIGHT study).

Long waiting times in the emergency department (ED) is an increasing problem in the recent years and is expected to become an even bigger problem in the future Objective: We aimed to test the hypothesis whether increasing awareness of the time lapse with the treating physician, 2 hours after patient arrival, can reduce long patient turnaround time (TAT). In this prospective single-center cohort study we compared and analyzed patient TAT in the ED before and after implementation of a so called 'traffic light' moment 2 hours after patient arrival. At this 'traffic light' moment a team member contacted the treating physician to increased awareness over the time lapse. Difference in percentage of patients who stayed more than 4 hours in the ED before and after intervention was the primary outcome Results: Between October 2nd 2021 and January 2nd,2022 1494 patients were included for primary outcome analysis. A total of 419 patients (n=740, 56.6%) had a TAT of less than 4 hour in the ED before intervention, compared to 497 (n=754, 65.9%) after intervention (p <0.001). Median time spent in de ED before intervention was 3:40 (IQR 2:24 - 5:04) compared to 3:15 (IQR 2:03 - 4:38) after intervention (p<0.001). This simple and low-cost intervention reduces the ED length of stay significantly. Although multiple interventions will be required to ensure less patients spending more than 4-hours in the ED, a 'traffic light' moment can be a simple and an effective tool.

Speed and Accuracy of Recording Medication History by Pharmacists in Secondary Emergency Rooms.

In Japan, only few hospitals have pharmacists in their secondary emergency rooms to record medication history and provide drug information in real time. In this study, we investigated the benefits of pharmacist intervention in secondary emergency rooms by comparing the time taken by the pharmacists and non-pharmacists in the emergency room to record the medication history in the electronic medical record and the accuracy of its content. The study period was from September 1 to September 30, 2022, and included patients who were transported to our hospital for emergency care between 9:00 and 16:30. We compared the time taken between the patient's arrival until the recording of their medication history and the accuracy of the record by the emergency room pharmacists and non-pharmacists (paramedics or medical clerks). The study included 58 patients whose medication histories were collected by pharmacists, and 11 patients whose histories were collected by non-pharmacists. For pharmacists, the median time to record medication history in the electronic medical record was 12 min, whereas for non-pharmacists, it was 19 min, which was significantly different (p=0.015). The pharmacists accurately recorded the medication history of 98.3% (57/58) of patients, whereas non-pharmacists accurately recorded it for only 54.5% (6/11) of patients, with a significant difference (p<0.01). We observed that in secondary emergency rooms, when pharmacists were responsible for recording the patients' medication histories, it resulted in rapid and accurate sharing of medication history.

Identifying potentials for Artificial Intelligence-based process support along the emergency department care pathway to alleviate overcrowding

This study examines the challenge of overcrowding within Emergency Department (ED) processes and elucidates the potential for AI-based interventions to enhance patient care and operational efficiency. We used qualitative interviews conducted in two German hospitals to identify five challenges along the ED care pathway: limited demand predictability, task overload, information unavailability, lack of IT systems interoperability, and low process standardization. We propose AI-based solutions to target these issues. For example, demand forecasting models could optimize resource allocation during patient arrival, while AI-guided queries and Decision Support Systems could improve data quality and standardization in registration & triage and diagnosis & treatment, respectively. Additionally, AI-driven text recognition and monitoring could streamline information management and patient observation. While the study is constrained by its geographic and methodological scope, it is foundational work for future research, including Design Science Research approaches to validate and implement the proposed AI-based process aids in the ED.

Managing Home Health-Care Services With Dynamic Arrivals During a Public Health Emergency

We consider a public health emergency, during which a high number of patients and their varying health conditions necessitate prioritizing patients receiving home health care. Moreover, the dynamic emergence of patients needing urgent care during the day should be handled by rescheduling these patients. In this article, we present a reoptimization framework for this dynamic problem to periodically determine which patients will be visited in which order on each day to maximize the total priority of visited patients and to minimize the overtime for the health-care provider. This optimization framework also aims to minimize total routing time. A mixed-integer programming (MIP) model is formulated and solved at predetermined reoptimization times, to assure that urgent patients are visited within the current day, while visits of others may be postponed, if overtime is not desired or limited. The effectiveness of a schedule is evaluated with respect to several performance metrics, such as the number of patients whose visits are postponed to the next day, waiting time of urgent patients, and required overtime. The MIP-based approach is compared to two practical heuristics that achieve satisfactory performance under a nervous service system by excelling in different criteria. The MIP-based reoptimization approach is demonstrated for a case during the COVID-19 pandemic. We contribute to the home health-care literature by managing dynamic/urgent patient arrivals under a multiperiod setting with prioritized patients, where we optimize different rescheduling objectives via three alternative reoptimization approaches.

Assessing the Severity of ODT and Factors Determinants of Late Arrival in Young Patients with Acute Ischemic Stroke.

Acute ischemic stroke (AIS) is increasingly affecting younger populations, necessitating prompt thrombolytic therapy within a narrow therapeutic window. Pre-hospital delays are prevalent, particularly in China, yet targeted research on the youth population remains scarce. In this retrospective cohort study, data from AIS patients aged 18-50 admitted to Longhua District People's Hospital, Shenzhen from December 2021 to December 2023 were analyzed using XGBoost and Random Forest machine learning algorithms, coupled with SHAP visualization, to identify factors contributing to pre-hospital delays. Among 1954 AIS patients, 528 young patients were analyzed. The median time to hospital arrival was 8.34hours, with 82.0% experiencing delays. Analysis of different age subgroups showed that young patients aged 36-50 years old had a higher delay rate than patients under 36 years old. Machine learning algorithms identified stroke awareness, age, TOAST classification, ambulance arrival, dysarthria, mRS on admission, dizziness, wake-up stroke, etc. as important determinants of delay. This study highlights the necessity of machine learning in identifying delay risk factors in young stroke patients. Enhanced public education, particularly regarding stroke symptoms and the use of emergency services, is crucial for reducing pre-hospital delays and improving patient outcomes.

ED arrival of patients with bleeding esophageal varices; timing of endoscopic intervention

ED arrival of patients with bleeding esophageal varices; timing of endoscopic intervention

Efficiency and perceived safety of foot and ankle procedures performed on the preoperative stretcher versus operating room table.

Foot and ankle surgeons often perform minor surgeries on the preoperative stretcher instead of the operating room table. We examined whether stretcher-based and operating room table-based procedures differed with respect to operating room efficiency and staff perceptions. We retrospectively reviewed medical records of patients undergoing minor foot and ankle surgery at an ambulatory surgery centre. We collected 'time to start', the duration between patient arrival in the operating room and incision time, and 'time to exit', the duration between procedure end time and patient exit from the operating room. Staff were surveyed regarding their perceptions of stretcher-based and operating room table-based procedures. 'Time to start' was significantly shorter for stretcher-based procedures, but 'time to exit' was not. Seventeen (81%) staff members thought stretcher-based procedures increased operating room efficiency. Thirteen (62%) thought stretcher-based procedures bettered staff safety. Nineteen (91%) thought stretcher-based procedures were equivalent to or better than operating room table-based procedures for patient safety. Most (67%) would recommend stretcher-based procedures. We found small but significant time savings associated with stretcher-based procedures. Without adapting surgical scheduling practices, the impact of stretcher-based procedures on overall operating room efficiency is questionable. Nevertheless, the majority of OR staff think stretcher-based procedures increase OR efficiency and are safer for staff. Level IV, Retrospective case series.

Peningkatan Pelayanan Laboratorium Dengan Memprediksi Kedatangan Pasien Menggunakan Metode Monte Carlo

The number of patient visits to the laboratory is unstable sometimes decreasing and increasing, when the increase in the number of visits to the laboratory makes everything disrupted because the number of patients who come is not proportional to the staff who are working / assigned at that time in the laboratory. So that some patients do not even get thorough service and even some patients wait too long in the queue. This causes services in the laboratory to be hampered, disrupted and become less than optimal. So the laboratory must be able to overcome this problem by knowing the number of visits to the laboratory in the future. So the researchers conducted this study with the aim of providing accurate information regarding the prediction of the number of patient arrivals to the laboratory with the application of the Monte Carlo Method. This method is a method that is often used to solve problems that are often related to uncertainty. The data used in this study is the last 3 years of patient arrivals to the laboratory with the frequency of arrivals from January to December. The results of this research are compacted accuracy of 87% in 2020 and 91% in 2021. So that the laboratory can take action on services in the future and make this research as a reference material.

Risk Analysis of Malpractice at Central General Hospital Friendship Jakarta

In the world of health services, many risks may be used as legal cases, ranging from the arrival of patients' data collection until patients leave the place of service. Europe and America have characteristics of different types of malpractice incidents, and in Asia, there are both developed, developing, and underdeveloped countries. This study aims to examine and analyze the prevention of malpractice risk and the mechanism of malpractice risk at Friendship Center General Hospital. The research methods used are empirical and conceptual juridical research methods. Researchers use literature studies as a tool for collecting research materials. The results of the study found that Permenkes 11 of 2017 states that Patient Safety aims to improve the Quality of Service in health Service Facilities through the application of Risk Management in all Aspects of Health Services, which means that it is expected that with the application of good Risk management, the risk for complaints that lead to malpractice reporting in any form can be suppressed in such a way. Although the application of standard operating procedures in hospitals, the risk of malpractice complaints is still possible due to many things from various angles that cannot be explained in the regulations or cannot be explained due to other things regarding the ability of doctors/service officers to convey information about problems or obstacles obtained at the hospital including facilities and other unwritten rules, So even though it has been prepared in such a way, the risk still occurs.

To Study Correlation between MOD Score and Biomarker Values for Early Prediction of MODS in Suspected Cases of Sepsis Cases in Hospital

Background: Utility of biomarkers in early prediction of multiple organ dysfunction syndrome (MODS) in suspected cases of sepsis presenting to the Emergency Department (ED). Aim and Objectives: To correlate the biomarker values (Pro-calcitonin (PCT), C-reactive protein (CRP), NT-pro BNP and Neutrophil gelatinase associated lipocalin (NGAL) with multiple organ dysfunction (MOD) score and to evaluate their role in early prediction of MODS in suspected sepsis patients presenting to ED. Methods: This is a prospective observational study conducted on 65 patients with suspected sepsis. Patients of 18-65 years presented in the ED with triage complaints of fever, respiratory, urinary and abdominal infections, who were sepsis screen positive on arrival and admitted, were enrolled in the study. They were categorized into two groups: Group 1 (MODS score Positive at 48 or 72 hours) and Group 2 (MOD score Negative). Biomarker values in both the groups and its correlation with MOD score was analyzed. Results: At 48 hours, 40 (61.5%) patients were MODS positive with PCT (Sensitivity 100%, OR-12.6, CI-0.6-255.04, p=0.098), CRP (Sensitivity 100%, OR-27.0, CI-1.44-504.0, p=0.027), NTpro BNP (Sensitivity 82.5%, OR-7.07, CI-2.55-22.16, p=0.0008) and NGAL (Sensitivity 77.5%, OR-82.9, CI-9.7-698.16, p=0.0001) with PPV of NGAL (96.88%) and NT-pro BNP (76.74%) and 100% NPV for PCT and CRP. Conclusion: This study established a good correlation of NT-pro BNP and NGAL with positive MODS score suggestive of and highly predictive of developing MODS in suspected cases of sepsis. The normal value of PCT and CRP on arrival in patients with suspected sepsis rules out MODS even at 72 hours during their hospital stay.

Accuracy of Prehospital Services' Estimated Time to Arrival for Ground Transport to the Emergency Department

BackgroundEmergency medical services (EMS) transporting patients to the emergency department (ED) typically call ahead to provide an estimated time to arrival (ETA). Accurate ETA facilitates ED preparation and resource allotment in anticipation of patient arrival. ObjectiveThe study purposed to determine the accuracy of ETA provided by EMS ground units. MethodsWe performed a single-center, prospective, observational study of ED patients arriving via EMS ground transport. The primary outcome was the time difference between EMS-reported ETA and actual time of arrival (ATA). The difference between ATA and ETA was compared using the two-sided Wilcoxon Signed-Rank Test. Subgroup analysis was performed to evaluate ETA accuracy for specific types of transports and assess variability by month and time of day. ResultsWe included 1176 patient transports in the final analysis. The overall median difference ATA-ETA was 3 min (interquartile range 1–5 min) with a range of −26–48 minutes (Z = −25.139, p < 0.001). EMS underestimated ETA in 961 cases (81.7%), and 94 ETAs (8.0%) were accurate to within 1 min. The largest difference between ATA and ETA occurred between 07:00–07:59 and 16:00–16:59 (5 min, interquartile range 2–7). ConclusionOur data demonstrate that prehospital providers underestimate time to ED arrival in most ground transports; however, the median difference between estimated and actual time to arrival is small.

Clocking the Processes and Challenges of Urgent Red Blood Cell Exchange for Acute Complications of Sickle Cell Disease

Background: Red blood cell exchange transfusion (RBCX) is the therapy of choice for some acute complications of sickle cell disease (SCD), including stroke, severe acute chest syndrome and multi-organ failure. Rapid initiation of RBCX is critical to reduce morbidity and mortality in those with acute complications of SCD. A typical RBCX procedure requires anywhere from 6-10 units of packed red blood cells (RBC) and measures are taken to provide higher-fidelity RBC matches (key RHCE and KEL antigens at a minimum, ±suitable KIDD, FY, Ss profiles for the sensitized). Our recent review of urgent apheresis transfers to our tertiary-care centre, including 26 for RBCX, demonstrated that the median time per transfer was approximately 4 hours. Not yet characterized is the additional time required to start RBCX once a patient arrives. The time required to investigate antibody repertoires, and to procure sufficient quantities of blood that can bypass these specificities, is of interest in a specialty center with substantial but not unlimited investigative expertise and inventory. Methods: This was a retrospective database and chart review of all patients referred to our apheresis service for urgent RBCX for severe complications of SCD between Jan 1, 2013 to Dec 31, 2020. Time stamps for admission, blood bank, and apheresis processes were extracted from the electronic medical record and blood bank database. Categorical variables were analyzed using nonparametric tests. Results: Thirty-eight patients were included (65.8% males, 35.2% females) (Table 1). HbSS was the most common SCD genotype represented (81.6%). Most patients (71.1%) were transferred from another hospital, with the remaining patients arriving through the emergency department (26.3%) and one (2.6%) as a direct admission from clinic. ACS +/- additional complications constituted the most common indication for RBCX (78.9%). Two patients died due to complications of multi-organ failure, the remaining patients were discharged from hospital. Six patients (15.8%) had a positive antibody screen. The majority had RBC phenotype (42.1%) or genotype +/- phenotype (36.8%) on file to facilitate extended matching, and sufficient appropriate units were available in the blood bank in 82% of cases. Four (10.5%) patients required top-up transfusions prior to RBCX due to significant anemia. The median number of units issued per procedure was 9 (IQR 2). The median times from index group and screen (G&amp;S) collection to sample accession, and from accession to result were 23 minutes (IQR 26) and 46 minutes (IQR 31), respectively (Figure 1). The median time from G&amp;S result to RBC units issued was 348.5 minutes (IQR 479). The median total time from patient admission (or determination of RBCX indication) to RBC units issued was 569 minutes (IQR 464). A positive antibody screen, patient origin (ED vs. transfer), and the availability of sufficient RBC units in house were associated with turnaround time from accession of the index G&amp;S sample to the issuing of RBCs (p&amp;lt;0.01 for all). Patients having antibodies to high prevalence antigens (e.g. anti-U) or to multiple targets (demanding unique donor profiles) had some of the longest times to initiate treatment. These constraints necessitated orders and coordinated deliveries of units from across the geographic network of the national blood provider.Discussion: These data from the largest apheresis unit in the country characterize the time invested in blood preparation for an urgent RBCX for acute SCD complications. A positive antibody screen is predictive of increased time to procedure start, reflecting delays inherent to serologic investigations, product sourcing, and serologic crossmatch times. While the precise moment of a blood request was available for a minority of patients, the G&amp;S time stamp was used as a surrogate, thus potentially overestimating turnaround times in the blood bank. Nevertheless, the serologic demands inherent to a case present a tension between speed (treating the disease) and safety (averting immune rejection reactions).

Machine learning detects symptomatic patients with carotid plaques based on 6-type calcium configuration classification on CT angiography.

While the link between carotid plaque composition and cerebrovascular vascular (CVE) events is recognized, the role of calcium configuration remains unclear. This study aimed to develop and validate a CT angiography (CTA)-based machine learning (ML) model that uses carotid plaques 6-type calcium grading, and clinical parameters to identify CVE patients with bilateral plaques. We conducted a multicenter, retrospective diagnostic study (March 2013-May 2020) approved by the institutional review board. We included adults (18 +) with bilateral carotid artery plaques, symptomatic patients having recently experienced a carotid territory ischemic event, and asymptomatic patients either after 3months from symptom onset or with no such event. Four ML models (clinical factors, calcium configurations, and both with and without plaque grading [ML-All-G and ML-All-NG]) and logistic regression on all variables identified symptomatic patients. Internal validation assessed discrimination and calibration. External validation was also performed, and identified important variables and causes of misclassifications. We included 790 patients (median age 72, IQR [61-80], 42% male, 64% symptomatic) for training and internal validation, and 159 patients (age 68 [63-76], 36% male, 39% symptomatic) for external testing. The ML-All-G model achieved an area-under-ROC curve of 0.71 (95% CI 0.58-0.78; p < .001) and sensitivity 80% (79-81). Performance was comparable on external testing. Calcified plaque, especially the positive rim sign on the right artery in older and hyperlipidemic patients, had a major impact on identifying symptomatic patients. The developed model can identify symptomatic patients using plaques calcium configuration data and clinical information with reasonable diagnostic accuracy. The analysis of the type of calcium configuration in carotid plaques into 6 classes, combined with clinical variables, allows for an effective identification of symptomatic patients. • While the association between carotid plaques composition and cerebrovascular events is recognized, the role of calcium configuration remains unclear. • Machine learning of 6-type plaque grading can identify symptomatic patients. Calcified plaques on the right artery, advanced age, and hyperlipidemia were the most important predictors. • Fast acquisition of CTA enables rapid grading of plaques upon the patient's arrival at the hospital, which streamlines the diagnosis of symptoms using ML.

Adolescent Trauma Patients With Isolated Head Trauma and Glasgow Coma Scale 6-8: Routine Intubation?

Recent evidence suggests that routine intubation upon arrival for adults with isolated head trauma and a depressed Glasgow Coma Scale (GCS) score is associated with increased risk of morbidity and mortality. Whether these outcomes are similar within an adolescent trauma population has not been previously investigated. We hypothesized intubation upon arrival for adolescent trauma patients with isolated head trauma to be associated with a higher risk of death and prolonged length of stay (LOS). The 2017-2019 TQIP was queried for adolescents (age 12-16) presenting after isolated blunt head trauma (abbreviated injury scale [AIS] <1 spine/chest/abdomen/upper-extremity/lower-extremity) and GCS 6-8 on arrival. Transferred patients, dead-on-arrival, and those undergoing emergent operation from the emergency department were excluded. Patients intubated within one-hour were compared to patients not intubated within one-hour. A multivariable logistic regression analysis was performed adjusting for age, sex, GCS, and AIS-grade for the head. From 141 patients, 73 (51.8%) were intubated upon arrival. Intubated patients had a low complication rate (5.6%). Intubated and non-intubated patients had a similar rate and mortality risk (6.8% vs 1.5%, P = .11) (OR 1.84, CI .08-43.69, P = .71) and median length of stay (LOS) (2days vs 2days, P = .13). Unlike adult patients, adolescents with isolated head trauma and a depressed GCS have similar outcomes if they are intubated upon arrival. Utilizing initial GCS score to determine which adolescent trauma patients with isolated head trauma should be intubated appears to be a safe practice.

Improvement of microcirculatory vessel density in the early post-operative period of heart valve surgery: an observational study

Abstract Introduction Cardiac surgery with cardiopulmonary bypass (CPB) is associated with microcirculatory perfusion disturbances that persist after the surgery and that can cause multiple organ dysfunction. Little is known about the effects of heart surgery on the microcirculation of patients in the postoperative period of heart valve surgery. Purpose The purpose of the study is to identify the alterations that occur in the sublingual microcirculation of patients submitted to heart valve surgery using cardiopulmonary bypass. Such findings may guide future implementation of routine microcirculation assessment in the postoperative period of cardiac surgery. Methods This was a single-center cross-sectional observational study that included thirty patients aged 52 ± 14 years and enrolled during a period of four months, scheduled for heart valve surgery with CPB at a quaternary public hospital. Sublingual microcirculatory density and perfusion were assessed using a handheld camera based on incident dark-field (IDF) imaging. Each recruited patient was evaluated in two stages: 1) during hospitalization, in the preoperative period of cardiac surgery to be performed within the next 48 hours; 2) in the early postoperative phase of cardiac surgery, within the first four hours of the patient's arrival at the intensive care unit. At least three videos of 5 seconds each were obtained in both stages. Images were analyzed using automated software as well as visual analysis. For analysis purposes, we considered vessels as capillaries if diameter ranges between 6.04-15.9 µm and non-capillaries if diameter ranges between 16-50 µm. Results We observed a statistically significant increase in the total number of vessels (TVN) after surgery (1076 ± 156) compared to values obtained before surgery (943 ± 117, P=0.0004). In addition, the total number of capillaries vessels (TNCV) was also greater after surgery (998 ± 132) compared to the preoperative period (877 ± 106; P=0.0001), the same being observed in the total length of capillaries vessels (TLCV) after surgery (28.7 ± 3.3 mm) compared to before surgery (25.8 ± 3.0 mm; P=0.0005) and capillary vessel density (CVD) (16.4 ± 1.9 and 14.8 ± 1.7 mm/mm2) after and before surgery, respectively (P=0.0005). With regard to non-capillary vessels, no difference was observed in total number of non-capillary vessels (TNNCV) after [68 (49-104)] and before surgery [69 (49-78)] (P=0.21), as well as in total length of non-capillary vessels (TLNCV) after [1.6 (1.2-2.4)] mm and before [1.5 (1.1-1.8.)] mm (P=0.25) surgery. Finally, non-capillary vessel density (NCVD) was also similar after [0.89 (0.67-1.36)] mm/mm2 and before surgery [0.83 (0.66-1.06)] mm/mm2 (P=0.34). Conclusion In patients undergoing heart valve surgery, there was a significant increase in postoperative microvessel number, mainly due to the increase in the density of capillaries vessels.

Abstract 14671: Investigating Health Disparities in Arrival From Last Known Well Times in Queens, NY

Background: Stroke is a leading cause of death in the US and the third leading cause of disability worldwide, so timely access to care must be considered as it is a salient predictor of prognosis and outcomes. 1,2 Specifically, because the recommended treatment window for IV tPA (alteplase) is within 4.5hr of last known well (LKW), it is imperative for patients to present to the facility within 3.5hr from symptom onset to receive treatment. 3 There are known health disparities in stroke treatment/outcomes 4 , and this study seeks to explore the population of patients that disproportionately have unknown or LKW &gt;4.5hr to arrival, and the impacts of such. Methods: Stroke patients entered into the Get With The Guidelines™-Stroke excluding patients whose symptoms began after hospital arrival and were discharged from October 2021 to December 2022 from NYC Health + Hospitals/Queens were included. Arrival from LKW time was categorized into ≤0-4.5hr and &gt;4.5hr. Covariates collected and included are age, Hispanic ethnicity, sex, race, final clinical diagnosis of stroke, and history of previous stroke. Logistic regression models were used to analyze data and results are presented as adjusted odds ratios at 0.05 significance. Results: A total of 342 patients were included in this study with 211 patients arriving after 4.5hr. The median time to arrival from LKW was 829min. Notably, patients identifying as Asian were more likely to arrive within 4.5hr of LKW (3.21 adjusted OR, 95% CI 1.30-7.91, p = 0.01) compared to their Black counterparts. White patients were also more likely to arrive within the 4.5hr treatment window compared to Black patients (11.69 adjusted OR, 95% CI 3.39-40.36, p = 0.0001). Increase in age was associated with decrease in timely arrival from LKW (0.98 adjusted OR, 95% CI 0.96-0.99, p = 0.04). Clinically, those that were diagnosed with ischemic stroke were more likely to arrive within 4.5hr of LKW (2.55 adjusted OR, 95% CI 1.37-4.77, p = 0.003) as well as those with a history of previous stroke (2.74 adjusted OR, 95% CI 1.39-5.40, p = 0.004). Conclusion: There are health disparities in stroke treatment because of prolonged patient arrival from or unknown LKW, and these findings will help inform further practices in community education and outreach.

Abstract 253: Impact of Gender and Marital Status on Door‐To‐Needle and Door‐To‐Puncture time and Acute Stroke Outcome

Introduction Delays in acute treatment of ischemic stroke have been associated with worse outcomes [1]. Women are more likely to present with atypical stroke symptoms than men, causing delay in pre‐hospital diagnosis and seeking medical attention [2‐3]. Additionally, women tend to be older at stroke onset and more likely to be living alone [4‐5]. Among patients presenting with acute stroke, women experience longer emergency department (ED) door‐to‐doctor and door‐to‐imaging (DIT) times, resulting in fewer interventions [6]. It is unclear if gender disparities in the timeliness of ED arrival and stroke assessment are compounded by gender differences in timeliness of treatment after patient arrival in the ED. Therefore, we sought to identify, if gender and marital status were associated with faster door‐to‐needle (DTN) and door‐to‐puncture (DTP) times. We hypothesized that married men would have the fastest DTN and DTP times, associated with female spouses being quicker to recognize traditional signs of stroke, calling 911 who can activate stroke alert, and therefore avoiding delay in acute care. Methods Our single‐center stroke database was queried for adults presenting to the ED with acute stroke between 1/1/2018‐1/30/2023. Patients were excluded if they had missing data on marital status or covariates. DTN and DTP times, as well as National Institutes of Health Stroke Scale (NIHSS) at discharge, were analyzed using quantile regression on sex, marital status (dichotomized as married vs. single), age, intervention (TPA alone, or thrombectomy±TPA), and NIHSS score at presentation. Results We identified 674 patients meeting inclusion criteria, of whom 31 were excluded due to missing data. In the remaining sample (N=643, median age 66yr), 25%/18% of patients were married men/women, respectively, and 22%/35% were single men/women. Median DTN time, DTP time, and discharge NIHSS were 36min, 79min, and 4, respectively. On multivariable analysis (Table), none of the outcomes were improved among married men relative to any other combination of sex and marital status. Conclusion Gender differences in knowledge of warning signs of stroke in community‐based studies and gender disparities in ED assessment did not translate into faster treatment “after” ED arrival based on gender or marital status. More work is needed to find out ways to accelerate care “after” ED arrival to have faster DTN and DTP time.

Reducing time toxicity: Impact of a fast-track infusion pathway on overall wait-times and patient satisfaction at a large safety-net health system.

386 Background: Time toxicity is an emerging concept focusing on the impact of cancer care beyond traditionally measured outcomes: the time spent towards receiving care. Although the inherent complexity of cancer care can pose a challenge to improve time toxicity, addressing system and workflow inefficiencies through process improvement is an effective mitigation strategy. Here we present the impact of a fast-track infusion pathway on the wait-times and patient satisfaction at a large safety-net system. Methods: Parkland Health (PH) is the safety-net system for Dallas County, TX. The PH oncology infusion center supports cancer disciplines and other subspecialties. Factors such as timely patient arrivals, preference for coupled visits and same-day lab draws, and heterogeneity of treatments (medicine specialties vs. oncology) significantly impact wait times. In July 2022, a multidisciplinary team was formed to reduce wait times at the infusion center, including members who had previously participated in the ASCO Quality Training Program (QTP). This report is focused on developing a fast-track pathway for patients with injections or &lt;30-minute infusions. Patients with coupled appointments and same-day lab draws were eligible for fast-track. Wait times were calculated from the time patients were checked in at the front desk to the first medication administered. A dedicated team (RN and MA) and separate waiting areas/infusion bays were designated for fast-track patients. Fast-track patients were surveyed for satisfaction. Results: Baseline infusion volume for the 3 months prior to fast-track implementation was 106 patients per day with average wait time of 167 minutes. In the seven-month period after fast-track implementation, average daily fast-track and main infusion center combined volume was 115. The first PDSA cycle was focused on improving workflows and communication with pharmacy. In the second PDSA cycle, the fast-track infusions were moved to another area to infusion chairs to better patient flow. In May 2023, average volumes and wait times for fast-track and main infusion were 28/80 minutes and 87/107 minutes, respectively. This represents a 40% decrease in wait time for fast-track and 36% for main infusion. In our survey, 89% of fast-track patients reported their wait time to be shorter and 92% rated their experience good or excellent. Conclusions: Implementing and optimizing a separate process for short treatments reduced the wait times for both the short infusions (fast-track) as well as long infusions (main infusion) without a need for additional staff, infusion chairs, or space. The observed decrease in main infusion wait-time is likely the result of decongestion of their process by moving some of the volume to fast-track. We hope to further decrease our wait-times through additional PDSA cycles and leveraging process improvement methodology.

ICU patient flow: To premature step-down or not? A simulation analysis

ABSTRACT A Step-Down Unit (SDU) provides an intermediate Level of Care for patients from an Intensive Care Unit (ICU) as their condition becomes less acute. SDU congestion and upstream patient arrivals force ICU administrators to incur costs, either in the form of overstays or premature step-downs. Based on a proxy for patient acuity level called the ‘Nine Equivalents of Nursing Manpower Score (NEMS)’, patients were classified into high-acuity and low-acuity. Two patient flow policies were developed and simulated: one allowing for premature step-down actions when the system is congested and the other allowing for patient rejection actions when the system is congested. The results show that the patient-rejection policy has a net health service benefit that significantly exceeds the premature step-down policy. Based on these results, it can be concluded that premature step-down contributes to congestion downstream. Counter-intuitively, premature step-down should therefore be discouraged and patient diversion actions should be further explored as viable options for congested ICUs.