Order Placement Research Articles

Improving the referral rate of universal genetic counseling for pancreatic ductal adenocarcinoma (PDAC) at the Cleveland Clinic Taussig Cancer Center: A quality improvement project.

196 Background: While most PDAC are sporadic, up to 10% are inherited. In 2018, ASCO and NCCN guidelines were updated to recommend that all patients with PDAC be considered for genetic counseling (GC) and germline testing. Furthermore, interest in treating patients with targeted therapy, such as olaparib, for germline mutations is increasing. We implemented a quality improvement project to identify the referral rate to GC for patients with PDAC, with the goal of improving the referral rate to 60%. Methods: Barriers to GC referral were identified using quality improvement tools developed at the ASCO Quality Training Program. Three “plan, do, study, act” (PDSA) cycles were implemented: 1) updating the electronic order and tumor board template to include GC recommendation (Aug–Oct 2019), 2) physician education (Nov–Dec 2019) and 3) patient education and physician reinforcement (Jan–Feb 2020). Baseline data to evaluate impact of PDSA intervention (from April to June 2019) on documented discussions about GC and placement of the referral order was completed via chart review. Results: Between April 2019 to January 2020, 199 patients with PDAC were seen in medical oncology clinic as new patient visits. Thirteen patients had previously completed GC. For the remainder, baseline discussion and referral rates were 25% and 9%, respectively. Discussion and referral rates improved to 55% and 30% after PDSA 1, to 73% and 33% after PDSA 2, and to 95% and 58% after PDSA 3, respectively. Forty-nine patients were referred at the first visit and 23 were referred at a subsequent visit. Forty-six patients underwent GC. In patients who completed germline testing 8.9% (4/45) were found to have a pathogenic variant in BRCA2, TP53, ATM, and MUTYH. Conclusions: With increased physician and patient education, we were able to improve the GC discussion rate from 25% to 95% and referral rate from 9% to 58%. While we did not meet our aim of 60% GC referral rate, we identified obstacles and outlined an improved process for early GC referrals. Enacting processes to reinforce GC referrals for patients with PDAC is likely to increase detection of germline mutations in this population.

Effect of shield placement for transient voltage mitigation due to switching surges in a 33/11 kV transformer windings.

This study presents an investigation on the effect of shield placement for mitigation of transient voltage in a 33/11 kV, 30 MVA transformer due to Standard Switching Impulse (SSI) and Oscillating Switching Impulse (OSI) surges. Generally, the winding and insulation in transformers could experience severe voltage stress due to the external impulses i.e. switching events. Hence, it is important to examine the voltage stress and identify the mitigation action i.e. shield placements in order to reduce the adverse effect to the transformer windings. First, the resistances, inductances, and capacitances (RLC) were calculated for disc type transformer in order to develop the winding RLC equivalent circuit. The SSI and OSI transient voltage waveforms were applied to the High Voltage (HV) winding whereby the transient voltages were simulated for each disc. The resulting voltage stresses were mitigated through different configurations of electrostatic shield placements. The resonant oscillations generated due to switching surges were analysed through initial voltage distribution. The analyses on the transient voltages of the transformer winding and standard error of the slope (SEb) reveal that the location of shield placement has a significant effect on the resonant switching voltages. The increment of the shield number in the windings does not guarantee optimize mitigation of the resonant switching transient voltages. It is found that the voltage stress along the windings is linear once a floating shield is placed between the HV and Low Voltage (LV) windings of the disc-type transformer under the SSI and OSI waveforms. These findings could assist the manufacturers with appropriate technical basis for mitigation of the transformer winding against the external transient switching overvoltage surges.

Probabilistic Cache Placement in UAV-Assisted Networks With D2D Connections: Performance Analysis and Trajectory Optimization

With the exponential growth of data traffic, caching is regarded as a promising solution to combine with unmanned aerial vehicle (UAV)-assisted networks, which can offload cellular traffic and improve the system performance. Moreover, the cache capacity at user side can be leveraged, e.g., through local data storage or device-to-device (D2D) sharing. In this paper, we focus on the performance analysis and trajectory optimization of cache-enabled UAV-assisted networks with underlaid D2D communications. We consider both static and dynamic UAV deployments. For static UAV deployment, we first formulate an optimization problem to design the cache placement in order to maximize the cache hit probability. Then, the successful transfer probability (STP) and sum-rate are analyzed by using stochastic geometry, and their closed-form expressions are derived. For dynamic UAV deployment, the UAV moves over the cell and stops at several path points to serve users. To shorten the time required for the UAV to cover all users, a spiral algorithm is proposed to optimize the UAV trajectory, aiming at minimizing the number of UAV path points. Moreover, since at different locations, the UAV communication will incur different interference on D2D users, we derive the outage probability for the D2D users. Simulation results show the significant performance gain of our proposed probabilistic cache placement over existing strategies. For a given user density, we show that the optimal values for the UAV height which lead to the maximum UAV-STP and sum-rate exist.

Order Execution Probability and Order Queue in Limit Order Markets

The shaping of a limit order book illustrates the dynamics of the trading process, the changing pattern of the execution probability of limit orders therefore plays an important role. This paper presents a computable execution probability model for limit order market, as well as a numerical example that intuitively characterizes the changing pattern of the execution probability. The common effects of the lengths of both buy and sell queues on the execution probability are explored. In the limit book, the cumulative probability of limit orders is introduced as a crucial index of market depth to describe the shaping process which brings new insights into the structure of the order placement decision.

Effect of Meropenem Restriction on Time Between Order and Administration in a Medical Intensive Care Unit

Background: In this study, we assessed whether meropenem restriction led to delays in administration for patients in a medical intensive care unit (MICU) at a large tertiary-care urban teaching hospital. Methods: The antimicrobial stewardship program (ASP) at Virginia Commonwealth University Health System (VCUHS) requires approval for restricted antimicrobial orders placed between 8 a.m. and 9 p.m. Between 8 a.m. and 5 p.m. (daytime), authorized approvers include ASP and infectious diseases (ID) physicians. From 5 p.m. to 9 p.m. (evening) orders are approved by ID fellows. Orders were entered as Stat, Now, and Routine. Between 9 p.m. and 8 a.m. (night), patients receive doses without approval. Meropenem restriction began in mid-January 2018. Pre- and postmeropenem restriction periods were defined as February–December 2017 and February–December 2018. Meropenem use data were compared for adult patients in the MICU. A multivariable Cox regression model was implemented to compare (1) time from order entry to approval; (2) time from order approval to patient administration; (3) total time from order entry to patient administration, adjusting for order priority, approver (ASP, ID consult, ID fellow, pharmacy); and (4) time of day of order placement (day, eve, night). The analyses were performed using SAS version 9.4 software (SAS Institute, Cary, NC). Result: Time from order approval to patient administration was significantly decreased in the postrestriction period (HR, 1.840; P < .001) (Table 1). Stat orders were faster compared to routine orders for order entry to approval (HR, 1.735; P < .001), approval to administration (HR, 2.610; P < .001), and total time from order entry to administration (HR, 2.812; P < .001). No significant differences were found in time to approval by approving service. Time from order entry to approval was faster for nighttime orders than for daytime orders (HR, 1.399; P = .037). Conclusions: Our data indicate that the time from order entry to administration decreased following meropenem restriction in our MICU. More research is needed to identify the reason for this finding, but we postulate that this is due to an effect on drug administration prioritization within nursing workflow. These data will inform our local meropenem restriction efforts.Funding: NoneDisclosures: Michelle Doll reports a research grant from Molnlycke Healthcare.

Multiple duration analyses of dynamic limit order placement strategies and aggressiveness in a low-latency market environment

This study examines dynamic order placement strategies in a low-latency environment together with limit orders' aggressiveness by a new approach which utilises survival analysis with a multiple-spell duration model. Two samples are considered, including the period immediately followed Australian Securities Exchange (ASX)’s migration to Integrated Trading System (ITS) and the period subsequent to the launch of ASX Trade. We find the evidence supporting both the ‘cost of immediacy hypothesis' and the ‘chasing hypothesis' as in Hasbrouck and Saar (2009). Furthermore, several distinctions in the results are found between the samples of ITS period and ASX Trade period as well as between the samples of small-cap stocks and large-cap stocks. The findings of this study are beneficial not only for high-frequency traders in forming dynamic order placement strategies in a low-latency stock market environment, but also for market regulators in helping their attempt to improve regulations for stock exchanges.

The use of a patient advocate to improve the experience in pediatric radiology.

There is increasing emphasis on improving the patient experience with a shift to patient- and family-centered care throughout all areas of health care. In 2013, the American College of Radiology launched Imaging 3.0, an initiative aimed at encouraging and enabling radiologists to work on culture change to increase focus on appropriateness, efficiency, quality, safety and patient satisfaction. Many groups have subsequently used these and other tools to improve the overall patient experience, focusing on the entire imaging journey to include initial order placement, registration in the department, image acquisition, departure from the department, and how and when the patient and family receive the imaging results. In our department we have used multiple strategies and have applied quality-improvement methods and patient/family-centered care models to improve quality, safety and the patient experience. Most of these efforts have included team members across the department, including radiologists, technologists, quality-improvement personnel, managers and nurses. In addition, for the last 12years, a key member of these teams has been our patient and family advocate (PFA). We describe the important role that a PFA can play in improving the patient and family experience in pediatric radiology.

Examining the value of flexible logistics offerings

In the order fulfilment and retail industry, the provision of fast and low cost delivery services has received significant focus over the last decade. What is often neglected is other factors that contribute to a customer’s overall experience like customisation and flexibility of deliveries, especially in cases when a customer’s needs and plans change between order placement and order delivery. This paper explores the value of a flexible type of logistics offering in which the customer is able to change the order requirements (such as delivery date) after the order has been placed. In particular, we focus on the interactions between a retailer and a customer in agreeing and executing such logistics orders. We examine the benefits of this type of flexible logistics offerings because flexibility and customisation are critical factors for the success of omni-channel commerce. Such offerings are clearly connected with recent developments in digital technologies as these technologies are essential for the implementation. Our results indicate that flexible logistics offerings can be beneficial both for retailers and for customers. They also highlight the importance of receiving orders that do not fully meet the requirements of a customer.

Price discovery, order submission, and tick size during preopen period

Using limit order book data, this study investigates the effects of minimum tick size reduction on price discovery and order submission strategies during the preopen call auction period in the Tokyo Stock Exchange. Studying the largest stocks' changes before and after the tick size reduction, our findings suggest that price discovery becomes more efficient when a smaller tick size is employed. A reduction in tick size induces a decrease in market depth and spread and enhances the speed of price discovery by encouraging more aggressive order to be placed and providing investors a better learning and communicating environment to incorporate information into order decisions. Our results demonstrate that, although orders are not matched and no transaction occurs during the preopen period, the order placement at these moments is neither necessarily noisy nor completely manipulative; factors that impact the investor's order choice during the normal trading period also work in this period.

103. IMPLEMENTATION OF A HEALTH LITERACY- INFORMED EDUCATIONAL INTERVENTION FOR CHILDREN AND CAREGIVERS DURING HOSPITALIZATION WITH ASTHMA

Background Asthma is the most prevalent chronic disease of children. Poor health literacy and ineffective teaching can result in poorer outcomes, increased Emergency Department visits, readmissions, and increased costs to the system. Aim Statement Our primary aims for this project are: 1) Increase the percent of families who receive multimodal asthma education (verbal, video, and handout) during hospitalization for asthma. 2) Decrease rates of inpatient hospital readmissions for asthmatics aged 2-18. Interventions A multidisciplinary QI team including physicians, nurses, respiratory therapists, and ancillary providers was formed. Chart audits were done to assess baseline documentation of asthma education on the acute care floors from July 2017 through February 2019. Three PDSA cycles were conducted with interventions including: 1) identification of asthma nurse champions and pilot of new educational materials to families on our pilot unit (March 2019); 2) training all unit staff on asthma education materials (April-May 2019); 3) improvement of electronic medical record asthma education documentation (June-July 2019). Statistical process control charts were used to assess the impact of these interventions. Measures Outcome measures were percent of encounters with any asthma education documented and readmission rates. Process measures were the percent of encounters with each multimodal (verbal, video, or handout) type. Balancing measures included hospital length of stay, time from admission to teaching, and time from discharge order placement to hospital discharge. Results Encounters with any asthma education documented increased from baseline of 63% to 84% post interventions, with special cause improvement noted. There was also an increase in video education from 0% to 65%. It is too early to report impact on hospital readmission rates which we continue to trend. Our interventions led to no change in our balancing measures. Conclusions and Next Steps We have been able to successfully increase the overall patient and caregiver asthma education as well as increase use of multimodal methods of asthma teaching. New multimodal education materials implemented have standardized the content and process for asthma education. Ongoing efforts are being made to produce sustained change and to spread asthma education hospital wide. We speculate the project has potential to influence population level asthma outcomes as we continue to expand our reach throughout the health system and community.

Klasifikasi impaksi caninus rahang atas pada pemeriksaan radiograf panoramik dan CBCT sebagai penunjang odontomy

Objectives: To assess the difficulty level of dental impaction treatment. This article discusses the problem of odontomy treatment based on the classification of maxillary canine impaction through panoramic radiograph examination and CBCT.
 Literature Review: Impacted tooth is pathological where the tooth fails to reach its normal functional position. Impaired maxillary canine second order placement after impact of third molars. The location of impacted jaw canine teeth most often occurs in the palatal region with a horizontal position according to the maxillary sinus and nasal cavity so that complications are required during odontomy. 
 Conclusion: Based on this literature study, classification on impacted maxillary canine teeth has been developed based on panoramic (2D) and CBCT (3D) radiography, so thus resulting in a complete classification of impacted maxillary canine teeth and can be used as a predictor of the difficulty level of maxillary canine tooth impaction treatment.

Patient reluctance to accept Do Not Resuscitate order: impact on clinical care.

A Do Not Resuscitate (DNR) order should only impede the performance of cardiopulmonary resuscitation in case of cardiac or respiratory arrest; it should not interfere with any other treatment decisions. To study the impact of DNR order placement on daily clinical care of patients. This was a retrospective cohort study of 72 patients in a tertiary care centre in Saudi Arabia. Daily clinical care measures were collected for 2 weeks prior and 2 weeks after DNR order placement and included vital signs, nursing care, comfort measures, documentation, visits by senior and junior physicians, and tests completed. Malignancy was the most common diagnostic category (43.1%). There was a significant reduction in vital signs documentation, tests completed, documentation, and visits by physicians after DNR orders, with no change in nursing care and comfort measures. No differences were seen for place of DNR order (intensive care unit vs medical ward), category of disease, or sex, but there were differences for documentation (more in females) and vital signs (more in males). More vital signs were documented and more tests were done in patients who survived compared to those who died. Regression analysis showed that the frequency of post-DNR order vital signs measurements and investigations done was not related to sex, age, diagnosis, time from admission to DNR order, or location of patients. Time to death was only related to sex and post-DNR order summary documentation. Placement of DNR orders significantly reduced vital signs measurements, investigations done, documentation and visits by physicians but not nursing care and comfort measures.

Work-Related Fatigue Among Inpatient Unit Nurses

Nurse fatigue has been recognized as a threat to both nurse and patient safety. Comparing to other units, inpatient unit has lower nurse to patient ratio. Inpatient unit nurses also work in shift and experience shift rotation. Thus make them more vulnerable to experience fatigue. The purpose of this study was to describe work-related fatigue among inpatient unit nurses. A cross-sectional, descriptive design with cluster sampling technique was used to 93 staffs nurses in six wards. Work-related fatigue was measured using Occupational Fatigue Exhaustion Recovery (OFER) scale. The data were analyzed using descriptive statistics. A total of 93 nurses provided their personal information details and fully completed self-reported fatigue and recovery questionnaire. The mean (±SD) scores were 56.55 (±15.56), 42.83 (±19.46), and 51.07 (±16.98) for acute fatigue, chronic fatigue, and intershift recovery, respectively. Perinatology unit nurses had the highest acute and chronic fatigue and the lowest intershift recovery. Less experienced nurses experienced lower acute fatigue level which tends to increase progressively with increasing experience and accompanied by poorer recovery. Nursing administrators should consider individual factors while planning staff placement in order to optimize quality of care and meet the job demands in every different unit.

Retailers' endogenous sequencing game and information acquisition game in the presence of information leakage

AbstractTimely and accurate order placement is critical to the success of all partners in a supply chain. This study explores the equilibrium states of the endogenous timing of order placement that could lead to information leakage in the supply chain. Competition and information asymmetry in the business environment adversely affect firms across industries, often leading to suboptimal outcomes. We examine the dynamics of two competing retailers and the impact of information leakage due to asymmetric information on their decision‐making strategies. Specifically, we analyze a supply chain with one supplier and two competing retailers under demand uncertainty in which the retailers' decisions on the timing of order placement and acquisition of demand information are endogenous. We characterize the retailers' choices in equilibrium and analyze the impact of these choices on their order quantities and profits. In reality, owing to outsourcing to overseas suppliers and long lead times, suppliers prefer early orders from their downstream partners. We find that a retailer that decides to invest to obtain demand information would end up ordering earlier than its competing firm even if information asymmetry and leakage exist. We also show that information is more valuable and beneficial to the retailer that has the first‐mover advantage.

To Discharge or Not to Discharge: Tachycardia in the Pediatric Emergency Department

Background: Tachycardia in the emergency department (ED) is associated with increased morbidity and mortality in adults. Tachycardia is also common in the pediatric ED, but its association with specific outcomes is less clear. Most American hospitals have adopted electronic health records (EHR) in recent years, allowing implementation of best practice alerts (BPA) to enhance diagnosis and improve outcomes. In our ED’s EHR, there is a BPA for abnormal vital signs, including tachycardia, upon placement of a discharge order. Purpose: To investigate the effect of the BPA for discharge tachycardia on clinical decision making, …

Quantity flexible contract under information asymmetry

ABSTRACT In this paper a quantity flexible contract is designed in a two-echelon supply chain with a single manufacturer and a retailer. Specific type of products are considered for which the customers place orders with the retailer prior to the beginning of the selling season. The exact demand is known to the retailer only at the beginning of the selling period once all the orders have been placed. The demand patterns during the period of the placement of orders from the customers are considered to be the private information of the retailer. Under such an environment of information asymmetry a contract between the manufacturer and the retailer is proposed which enables the retailer to order the exact realized demand from the manufacturer. The underlying adverse selection model is developed and analyzed in a principal-agent framework. The quantity flexible contract derived in this paper enables the retailer to place an order equal to the exact market demand for all types of demand patterns which the retailer may encounter; thus, the manufacturer receives his market share to the fullest extent. Under normal circumstances, the retailer may have to forego sales when situations of unusually high demand pattern arise, resulting in an opportunity cost. However, the quantity flexible contract derived in this paper enables the retailer to satisfy even such high demand. The contract design thus enables a win-win situation for the manufacturer as well as the retailer.

Inefficiency of the current system of forming the initial maximum price of the contract of the state construction order

Management of the investment cycle of construction requires the development of adequate measures to the modern challenges of innovative forms and methods of state regulation in the field of construction. The existing mechanism for the placement and implementation of the state construction order allows us to conclude that the public procurement management system is insufficient and requires further improvement, based on the development priorities of the innovation environment and the investment attractiveness of construction investment projects. In particular, one of the main components for placing a state construction order is to determine the initial maximum contract price, which affects the conditions for the implementation of a state construction order. The existing approach to the formation of the initial maximum price does not meet modern realities. The methodological foundations of the formation of the initial maximum price of the contract by dividing it into basic and managed components are considered. The separation of controlled factors into qualitative and quantitative indicators is proposed. Based on the study, it follows that through controlled factors, it is possible to influence the initial maximum price of the contract by changing the quality factors in particular.

2235-PUB: Improving Rates of Monitoring for Type 2 Diabetes Complications

Introduction: To compare our diabetes clinic’s baseline adherence to American Diabetes Association (ADA) and International Society of Pediatric and Adolescent (ISPAD) guidelines for obtaining urine creatinine/albumin ratio (ACR), liver enzymes (LFTs) and lipids at diagnosis with type 2 diabetes (T2D) to the rates of screening adherence following institution of educational flowcharts, revised note templates, and a best practice advisory (BPA). Methods: Data was extracted from Epic including all patients seen initially in our diabetes outpatient clinic with recently diagnosed T2D from 7/2014-8/2019. Data included dates of initial patient visits to our clinic and dates of ACR, LFTs, and lipid order placement or previous lab results. Vizio flowcharts and a revised clinic note template reflecting ADA/ISPAD guidelines were created and presented to the clinic’s 8 attendings and 5 APNPs in 7/2016. In 10/2017, a BPA alert containing the recommended labs began firing if T2D was on the patient’s problem list. A provider was considered adherent to the guidelines if labs were available from the previous 6 months or ordered within 120 days of diagnosis. Pre and post-screening rates were compared using the t-test. Results: Analysis included 40 patients diagnosed with T2D before any interventions and 39 after the 10/2017 BPA began. The improvement in urine ACR ordering rate was significant as it went from a baseline of 32.5% up to 82.1% (p<0.001), while improvements in the LFT ordering rate (60.0% up to 74.4%; p=0.2) and the lipid order rate (70.0% up to 79.0%; p=0.4) were not significant. Conclusion: With the implementation of the T2D flowchart, templated note, and BPA, adherence to ADA/ISPAD of ordering baseline screening labs rose to the 70-80% range. Given our aim to detect and treat complication as early as possible, and in order to increase reliability of our care, we are going to begin posting quarterly run charts so both the ordering provider and the diabetes nurses are consistently updated on our adherence rates. Disclosure P. Singh: None. P. Wolfgram: None.

Cost Analysis for In-house versus Industry-printed Skull Models for Acute Midfacial Fractures.

Background:Industry-printed (IP) 3-dimensional (3D) models are commonly used for secondary midfacial reconstructive cases but not for acute cases due to their high cost and long turnaround time. We have begun using in-house (IH) printed models for complex unilateral midface trauma. We hypothesized that IH models would decrease cost and turnaround time, compared with IP models.Methods:We retrospectively examined cost and turnaround time data from midface trauma cases performed in 2017–2019 using 3D models (total, n = 15; IH, n = 10; IP, n = 5). Data for IH models were obtained through itemized cost reports from our Biomedical Engineering Department, where the models were printed. Data associated with IP models were obtained through itemized cost reports from our industry vendor. Perioperative data were collected from electronic medical records.Results:The average cost for IH models ($236.38 ± 26.17) was significantly less (P < 0.001) than that for IP models ($1677.82 ± 488.43). Minimal possible time from planning to model delivery was determined. IH models could be produced in as little as 4.65 hours, whereas the IP models required a minimum of 5 days (120 hours) from order placement. There were no significant differences in average operating room time (P = 0.34), surgical complications, or subjective outcomes, but there was a significant difference in estimated blood loss (P = 0.04).Conclusion:Utilization of IH 3D skull models is a creative and practical adjunct to complex unilateral midfacial trauma that also reduces cost and turnaround time compared with IP 3D models.

Efficient Postoperative Disposition Selection in Pediatric Otolaryngology Patients: A Novel Approach.

Pediatric patients undergoing surgery on the aerodigestive tract require a wide range of postoperative airway support that may be difficult predict in the preoperative period. Inaccurate prediction of postoperative resource needs leads to care inefficiencies in the form of unanticipated intensive care unit (ICU) admissions, ICU bed request cancellations, and overutilization of ICU resources. At our hospital, inefficient utilization of pediatric intensive care unit (PICU) resources was negatively impacting safety, access, throughput, and finances. We hypothesized that actionable key drivers of inefficient ICU utilization at our hospital were operative scheduling errors and the lack of predictability of intermediate-risk patients and that improvement methodology could be used in iterative cycles to enhance efficiency of care. Through testing this hypothesis, we aimed to provide a framework for similar efforts at other hospitals. Quality improvement initiative. Plan, Do, Study, Act methodology (PDSA) was utilized to implement two cycles of change aimed at improving level-of-care efficiency at an academic pediatric hospital. In PDSA cycle 1, we aimed to address scheduling errors with surgical order placement restriction, creation of a standardized list of surgeries requiring PICU admission, and implementation of a hard stop for postoperative location in the electronic medical record surgical order. In the PDSA cycle 2, a new model of care, called the Grey Zone model, was designed and implemented where patients at intermediate risk of airway compromise were observed for 2-5 hours in the post-anesthesia care unit. After this observation period, patients were then transferred to the level of care dictated by their current status. Measures assessed in PDSA cycle 1 were unanticipated ICU admissions and ICU bed request cancellations. In addition to continued analysis of these measures, PDSA cycle 2 measures were ICU beds avoided, safety events, and secondary transfers from extended observation to ICU. In PDSA cycle 1, no significant decrease in unanticipated ICU admissions was observed; however, there was an increase in average monthly ICU bed cancellations from 36.1% to 45.6%. In PDSA cycle 2, average monthly unanticipated ICU admissions and cancelled ICU bed requests decreased from 1.3% to 0.42% and 45.6% to 33.8%, respectively. In patients observed in the Grey Zone, 229/245 (93.5%) were transferred to extended observation, avoiding admission to the ICU. Financial analysis demonstrated a charge differential to payers of $1.1 million over the study period with a charge differential opportunity to the hospital of $51,720 for each additional hospital transfer accepted due to increased PICU bed availability. Implementation of the Grey Zone model of care improved efficiency of ICU resource utilization through reducing unanticipated ICU admissions and ICU bed cancellations while simultaneously avoiding overutilization of ICU resources for intermediate-risk patients. This was achieved without compromising safety of patient care, and was financially sound in both fee-for-service and value-based reimbursement models. While such a model may not be applicable in all healthcare settings, it may improve efficiency at other pediatric hospitals with high surgical volume and acuity. N/A Laryngoscope, 131:S1-S10, 2021.