Total Patient Time Research Articles

Reducing Opioid Consumption and Length of Stay After Bariatric Surgery: A Nonpharmacologic ERAS Intervention Bundle

PurposeTo reduce opioid consumption and decrease length of stay (LOS) in bariatric surgical patients by implementing an evidence-based, nonpharmacologic enhanced recovery after surgery (ERAS) intervention bundle. DesignEvidence-based practice project. MethodsWe developed and implemented a nonpharmacologic ERAS bundle from existing American Society of PeriAnesthesia Nurses Standards and bariatric and subspecialty surgical ERAS protocols to standardize the postoperative nursing care of bariatric patients. The bundle consisted of early ambulation, immediate initiation and prolonged use of oxygenation, prevention of nausea and vomiting, frequent use of incentive spirometry, and application of ice packs to surgical sites. The two project outcomes were opioid consumption and patient LOS. We used descriptive statistics to summarize opioid consumption and LOS among surgical bariatric patients at baseline and post intervention and independent samples t tests to determine the statistical significance of pre- or post-LOS changes. FindingsAfter implementing the ERAS bundle in 31 bariatric surgical patients, we found that the percentage of patients given an opioid substantially decreased by 13.8%, with both fentanyl and hydromorphone (Dilaudid) consumption meaningfully decreasing by 11.0% and 25.6%, respectively. The average LOS significantly decreased (P = .015) by 23 minutes per patient following the intervention, from 1 hour and 58 minutes to 1 hour and 35 minutes, representing a 19.5% reduction in total patient time in the PACU. ConclusionsUse of a nonpharmacologic ERAS bundle and standardizing postoperative care decreased overall PACU bariatric surgical patient opioid consumption and significantly reduced PACU LOS. Optimizing pain management for bariatric patients in the PACU could lead to improved pain control and reduced reliance on opioids during their entire hospital stay, enhancing health care outcomes and improving patient safety. Perioperative leaders and educators can use our example to develop initiatives that decrease opioid use and LOS to improve care for the high-acuity bariatric patient population.

Decreasing Patient Visit Length at a Student-Run Free Clinic via a Continuous Quality Improvement Project.

The University of Florida Equal Access Clinic Network (EACN) is the largest student-run free clinic(SRFC) network in Florida. This student-driven, continuous quality improvement (CQI) project is intended to decrease total patient visit length at Eastside clinic, one of EACN's primary care sites. The original median visit length of 126.25 minutes represented a significant time burden for patients, especially those with limited transportation or inflexible schedules. Over six months, four Plan-Do-Study-Act (PDSA) cycles were implemented. PDSA cycle 1 increased personnel and space for taking vitals. PDSA cycle 2 reduced redundancy in the intake process. PDSA cycle 3 triaged patients to match patient complexity with student experience level. PDSA cycle 4 introduced "nudge" interventions to reinforce clinic flow. Total patient visit length and time spent at each step of clinic flow were recorded anonymously for each patient visit. The median visit length per week was tracked on a run chart. From PDSA cycle 1 through PDSA cycle 4, the median visit length decreased from 126 minutes to 114 minutes. This shift was primarily driven by a decrease in the length of patient intake from a median of 19 minutes to 9 minutes. The run chart did not show clear trends until PDSA cycle 4, which demonstrated a strong downward trend. This study demonstrated the ability of a student-driven CQI model to decrease patient visit length in an SRFC setting. Similar models could be used to address this and other contributors to patient experience across SRFCs nationwide.

Subcutaneous vs Intravenous Trastuzumab/Pertuzumab: A Time and Motion Substudy of a Phase II Trial of Adjuvant Trastuzumab/Pertuzumab for Stage I HER2+ Breast Cancer (ADEPT trial).

The time required for in-clinic drug administration can substantially affect breast cancer patients' quality of life. Subcutaneous (SC) drug administration, as opposed to intravenous (IV), may reduce this time commitment. This study sought to estimate the difference in time burden between IV and SC administration of trastuzumab and pertuzumab (HP). We prospectively enrolled a subcohort of patients participating in the ADEPT trial (ClinicalTrials.gov identifier: NCT04569747, investigating adjuvant HP plus endocrine therapy for stage I human epidermal growth factor receptor 2-positive breast cancer) to this single-arm crossover time and motion substudy. Patients received two cycles of IV HP followed by two cycles of SC HP. During each cycle, time points in drug preparation and administration were captured. The primary end point was total patient time in the treatment chair. Additional end points included total patient treatment experience time and total pharmacy workflow time. A sample size of 22 patients was estimated to provide 90.7% power with two-sided alpha .05 to detect a difference of 70 minutes in the primary end point by treatment arm (IV v SC). Twenty-two patients were enrolled. The mean total patient time in the treatment chair was 61.8 minutes shorter with SC versus IV HP (22.5 v 84.3 minutes; P < .0001). The mean total patient treatment experience time (incorporating time spent waiting for treatment initiation and time spent in the treatment chair) was 81.8 minutes shorter for SC administration (96 v 177.8 minutes; P < .0001). The pharmacy workflow time was 78.2 minutes shorter for SC versus IV formulation (41 v 119.2 minutes; P < .0001). SC administration of HP shortened patient time burden by approximately 1 hour. SC drug administration can facilitate faster workflows for health care professionals and improve patients' breast cancer treatment experience.

Comparison of propofol-based sedation and midazolam sedation in pediatric bidirectional endoscopy conducted by pediatric gastroenterologists.

The effectiveness and safety of propofol-based sedation and midazolam sedation in pediatric bidirectional endoscopy were compared. We retrospectively analyzed the cases of pediatric patients (≤15 years old) who had undergone bidirectional endoscopy, esophagogastroduodenoscopy, and colonoscopy by pediatric gastroenterologists. Demographic data, indications, sedatives/dosages, clinical outcomes, endoscopic findings, adverse events, and total patient time requirements (total time in which patients stay in our hospital) were compared in the two sedation groups. Ninety-one children (51 boys, 40 girls, mean age 13 years, range 9-15) treated at our hospital were enrolled. Propofol alone or in combination with midazolam and/or pentazocine was administered to 51 patients (propofol-based sedation group). Midazolam alone or in combination with pentazocine was administered to the other 40 patients (midazolam sedation group). In the propofol group, the following mean doses were used: propofol, 96 mg (range 40-145 mg); midazolam, 4.9 mg (range 3-5 mg); and pentazocine, 7.5 mg. In the midazolam group, the mean doses of midazolam and pentazocine were 6.2 mg (range 4-10 mg) and 15 mg, respectively. All procedures were successfully completed by pediatric gastroenterologists. The total procedure times and endoscopic findings were similar in the two groups, but the median patient time requirement in the propofol group was significantly shorter versus the midazolam group (7.3 h vs. 8.4 h, p < 0.001). No adverse events occurred in either group. Propofol-based sedation in pediatric bidirectional endoscopy was safely and effectively performed by pediatric gastroenterologists, and its patient time requirement was shorter than that for midazolam sedation.

Patient Time Spent With Professional Medical Interpreters and the Care Experiences of Patients With Limited English Proficiency.

More time spent with interpreters may support clinician-patient communication for patients with limited English proficiency (LEP), especially when interpreter support before and after clinical encounters is considered. We assessed whether more time spent with interpreters is associated with better patient-reported experiences of clinician-patient communication and interpreter support among patients with LEP. Patients with LEP (n = 338) were surveyed about their experiences with both the clinician and interpreter. Duration of interpreter support during the encounter (in min) and auxiliary time spent before and after encounters supporting patients (in min) were documented by interpreters. Multivariable linear regression models were estimated to assess the association of the time duration of interpreter support and patient experiences of (1) clinician-patient communication, and (2) interpreter support, controlling for patient and encounter characteristics. The average encounter duration was 47.7 min (standard deviation, SD = 25.1), the average auxiliary time was 43.8 min (SD = 16.4), and the average total interpreter time was 91.1 min (SD = 28.6). LEP patients reported better experiences of interpreter support with a mean score of 97.4 out of 100 (SD = 6.99) compared to clinician-patient communication, with a mean score of 93.7 out of 100 (SD = 14.1). In adjusted analyses, total patient time spent with an interpreter was associated with better patient experiences of clinician-patient communication (β = 7.23, P < .01) when auxiliary time spent by interpreters supporting patients before and after the encounter was considered, but not when only the encounter time was considered. Longer duration of time spent with an interpreter was associated with better clinician-patient communication for patients with LEP when time spent with an interpreter before and after the clinician encounter is considered. Policymakers should consider reimbursing health care organizations for time interpreters spend providing patient navigation and other support beyond clinical encounters.

T4 Integration of PT/OT in Burn Wound Care Increases Therapist Productivity

Abstract Introduction Inpatient physical (PT) and occupational (OT) burn therapists must balance complex patient factors such as daily wound care when attempting skilled therapy sessions, while also attaining specific productivity standards. These factors often lead to inefficient work flow and loss of productivity. The purpose of this study was to assess the productivity and feasibility of therapist integration into daily burn wound care. Methods A quality improvement project was initiated by the burn therapy team at our ABA verified burn center. One full time equivalent (FTE) PT or OT was assigned to the burn wound care team five days a week, involving 6 therapists (3 PTs and 3 OTs). General duties included wound assessment, functional wound dressings, and skilled therapeutic interventions. The primary outcome measure was individual therapist productivity tracked 3 months pre and 3 months post project implementation. Productivity was calculated by taking total billable patient time divided by total workday time, with a goal of 50% productivity. Billed time units were also compared to goal units. The results were analyzed using a paired t-test to measure significance and averaged. The secondary outcome measure was program feasibility, assessed by a qualitative questionnaire taken by burn staff pre and post. Results Overall therapist productivity increased, 49% pre implementation vs 54% post (p=0.0041). The difference of billed vs goal units increased, 5 pre vs 15.9 post (p= 0.00142). Proportion of therapists meeting target productivity increased, 57.1% pre vs 90.5% post (p=0.0052). Prior to program implementation, survey results found that 77% of burn staff (n=23 respondents) were favorable of project implementation, whereas 23% were either hesitant or indifferent. After 3 months post implementation, 95% of burn staff were favorable of therapist participation, 95% indicated ease of staffing burden, and 100% reported improved multidisciplinary communication. Furthermore, 100% of burn staff felt that the unit’s workflow had improved. Conclusions Full time therapy participation in wound care increases therapist productivity and increases the likelihood of meeting target productivity in the future. The majority of burn staff actively supported this pilot program and felt that it eased staffing demands, improved unit workflow, and improved multidisciplinary communication. Future efforts should focus on measuring specific patient outcomes and cost as a result of therapist participation in daily wound care practice. Applicability of Research to Practice All burn units should consider implementing a skilled burn therapist in wound care practice.

P432 Patient satisfaction and patient costs associated with telephone clinic appointments in Inflammatory Bowel Disease (IBD) following the pandemic

Abstract Background Prior to the COVID-19 pandemic, conventional management of outpatient care in IBD predominantly revolved around face-to-face clinic appointments. In the changing landscape of care provision during the pandemic, appointments were conducted almost exclusively through telephone consultation. An electronic questionnaire was developed to assess patient satisfaction and patient costs. Methods A pilot was carried out with 15 patients to identify any technical issues with e-mail delivery of the questionnaire and gauge face validity of the questionnaire content. 1400 patients registered with the TrueColours-IBD remote digital monitoring system were sent the questionnaire link via e-mail in May 2021. No demographic data were collected by design, in order to avoid the perception of bias and ensure freedom of expression through anonymity. Results 506 responses were received including 21 duplicates which were excluded, totalling 485 valid responses. 408/485 patients reported having a telephone appointment with the IBD service since March 2020, 484/485 reported having had a face-to-face appointment in the past. 348/408 (86%) were either ‘very satisfied’ or ‘somewhat satisfied’ with their most recent telephone consultation, while 22 (6%) were either ‘very dissatisfied’ or ‘somewhat dissatisfied’. 247/408 (61%) were also either ‘very satisfied’ or ‘somewhat satisfied’ with the ease of accessing further care if required, compared to 33/408 (8%) who were either ‘very dissatisfied’ or ‘somewhat dissatisfied’. Given the choice, 195/408 (48%) patients preferred to receive a telephone appointment in the future; 147/408 (36%) would opt for face-to-face and 66/408 (16%) stated no preference, all with the option of changing that choice if needed. Telephone appointments were associated with a mean total patient time off-work or leisure of 23 minutes (S.D. 51, n=408) compared to 190 minutes (S.D. 96, n=484) for face-to-face appointments. The average cost of time off work or leisure associated with telephone appointments was £5.55 (S.D. = £15.74, n=408), compared to £43.42 (S.D. = £31.27, n=484) for face-to-face appointments (Table 1). Costs of transport add further to face-to-face appointment costs. Greater proportions of patients had a companion for their face-to-face appointment and required childcare compared to telephone consultations (Table 2), which again increases the difference in costs. Conclusion Almost half of surveyed patients stated a preference for telephone appointments, although a third still preferred traditional follow-up. An evolution of care pathways is supported by patient preference and the statistically significant time and cost savings to patients receiving telephone appointments.

Automated Analysis of Treatment Log Files and Videos for MR-Guided Stereotactic Body Radiation Therapy Treatments of Thoracic and Abdominal Tumors

<h3>Purpose/Objective(s)</h3> MR-guided stereotactic body radiation therapy (MRgSBRT) is a novel method of treating mobile tumors with robust real-time gating and on-table adaptive planning. Delivery log files and cine videos of the treatment generated by the software system can be a rich source of information for assessing MRgSBRT treatment sessions. We hypothesized that developing scripts for automated review of MRgSBRT treatments using delivery logs and cine videos would be feasible. We have included a summary of our findings from our initial experience using this automated analysis. <h3>Materials/Methods</h3> We conducted a retrospective review of patients undergoing MRgSBRT for treatment of liver, lung, and pancreas tumors. Custom Python scripts were written to automatically extract treatment delivery information from log files and export data neatly into to a spreadsheet. A separate Python script was written to extract information from delivery cine videos using optical character recognition (OCR), color thresholding, and morphological processing as well. <h3>Results</h3> Using our automated system we were able to extract the following data points from the log files: treatment site, date and time of treatment, tracking algorithm configuration, average treatment duration, total dose, fraction (fx) number, MU per fx, couch shifts, and need for plan re-optimization. Additionally, through automated analysis of treatment cine video files we were able to extract frame by frame information for tracking structure centroid displacement, beam on/off status, frame-frame similarity, and tracking confidence (TC) over the course of treatment. Table 1 is an example of the data output. <h3>Conclusion</h3> Automated analysis of MRgSBRT delivery log files and log videos is feasible and can serve as a rich resource for QA/QI to improve treatment efficiency on an MR-LINAC by quantifying a multitude of measurable parameters and formulating strategies to address any unrealized bottlenecks in the process. Future plans include expanding our automation to examine total patient time on table, monitor units per beam segment, and predicting internal tumor volumes (ITV) based on tracking target displacement obtained from the delivery videos.

The Introduction of Robotics to an Outpatient Dispensing and Medication Management Process in Saudi Arabia: Retrospective Review of a Pharmacy-led Multidisciplinary Six Sigma Performance Improvement Project.

BackgroundOutpatient pharmacy management aims for improved patient safety, improved quality of service, and cost reduction. The Six Sigma method improves quality by eliminating variability, with the goal of a nearly error-free process. Automation of pharmacy tasks potentially offers greater efficiency and safety.ObjectiveThe goal was to measure the impact that integration of automation made to service, safety and efficiency, staff reallocation and reorientation, and workflow in the outpatient pharmacy department. The Six Sigma problem definition to be resolved was as follows: The current system of outpatient dispensing denies quality to patients in terms of waiting time and contact time with pharmacy professionals, incorporates risks to the patient in terms of mislabeling of medications and the incomplete dispensing of prescriptions, and is potentially wasteful in terms of time and resources.MethodsWe described the process of introducing automation to a large outpatient pharmacy department in a university hospital. The Six Sigma approach was used as it focuses on continuous improvement and also produces a road map that integrates tracking and monitoring into its process. A review of activity in the outpatient department focused on non-value-added (NVA) pharmacist tasks, improving the patient experience and patient safety. Metrics to measure the impact of change were established, and a process map analysis with turnaround times (TATs) for each stage of service was created. Discrete events were selected for correction, improvement, or mitigation. From the review, the team selected key outcome metrics, including storage, picking and delivery dispensing rates, patient and prescription load per day, average packs and lines per prescription, and lines held. Our goal was total automation of stock management. We deployed 2 robotic dispensing units to feed 9 dispensing desks. The automated units were integrated with hospital information technology (HIT) that supports appointments, medication records, and prescriptions.ResultsPostautomation, the total patient time in the department, including the time interacting with the pharmacist for medication education and counseling, dropped from 17.093 to 11.812 digital minutes, with an appreciable increase in patient-pharmacist time. The percentage of incomplete prescriptions dispensed versus orders decreased from 3.0% to 1.83%. The dispensing error rate dropped from 1.00% to 0.24%. Assessed via a “basket” of medications, wastage cost was reduced by 83.9%. During implementation, it was found that NVA tasks that were replaced by automated processes were responsible for an extensive loss of pharmacist time. The productivity ratio postautomation was 1.26.ConclusionsThe Six Sigma methodology allowed for rapid transformation of the medication management process. The risk priority numbers (RPNs) for the “wrong patient-wrong medication error” reduced by a ratio of 5.25:1 and for “patient leaves unit with inadequate counseling” postautomation by 2.5:1. Automation allowed for ring-fencing of patient-pharmacist time. This time needs to be structured for optimal effectiveness.

Waiting time from identification to recognition an occupational disease in Spain

ObjectiveTo estimate the waiting time since a suspected an occupational disease (OD) is identified, notified and recognized in Spain. MethodA series of 34 patients attended at Occupational Diseases Unit (ODU) of Hospital del Mar in Barcelona were follow up since their identification until final resolution by the National Institute of Social Security (INSS). Median, and 25 and 75 percentiles (interquartile range [IQR]) were calculated in weeks by total time (n=27), ODU time (n=34), patient time (n=31) and INSS time (n=27). ResultsTotal time was 51 weeks (IQR: 33.6 and 122.6), of which 42 weeks (17.6-99.5) corresponded to the waiting period at the INSS. ConclusionsThe disproportionately long waiting time since INSS receives a case could impact on the under-recognition of OD. Urgent improvement of the administrative process is needed to reduce the patient waiting time for the recognition of OD.

Abstract OT1-12-09: Time and motion study of a subcutaneous fixed-dose combination of pertuzumab and trastuzumab for the treatment of patients with HER2-positive early breast cancer (PHaTiMa)

Abstract Type: Trial in progress. Introduction: Sequential intravenous (IV) treatment with pertuzumab and trastuzumab is effective in disrupting HER2 signalling in early and advanced HER2-positive breast cancer (BC). However, this strategy increases patient’s length of stay at the hospital, healthcare professionals’ (HCP) workload, and the use of medical supplies and resources. The change from IV to subcutaneous (SC), and the combination of fixed doses of pertuzumab and trastuzumab in a unique ready-to-use vial is expected to save HCP and patient time, release resources and reduce the utilization of medical supplies. Moreover, reducing patient chair time and hospital time would improve their quality of life, help reduce indirect costs due to less work productivity loss and decrease patient exposure to nosocomial pathogens. This is the first randomized clinical trial capturing the time and resources associated with the fixed-dose combination of pertuzumab and trastuzumab for SC injection (PH FDC SC) compared with Perjeta (P) IV and Herceptin (H) IV/SC. Design: Multicentre, interventional, randomized Phase IIIb clinical trial that aims to recruit 33 adult patients with node-positive HER2-positive early BC from 10 centres across Spain. These patients will have been previously treated with neoadjuvant P + H + chemotherapy according to local practice and achieved a pathological complete response (pCR, defined as ypT0/is ypN0) after surgery. Patients will be randomized 1:1 to receive either P IV + H IV (group A) or P IV + H SC (group B), every 3 weeks (Q3W) for 4 cycles followed by PH FDC SC Q3W for 3 cycles. Primary endpoints are to evaluate the patient time in the care unit for each administration route, and the HCP time for SC and IV processes on a per patient visit and per complete treatment. Secondary endpoints comprise total patient time spent in hospital and resource utilization reduction in terms of consumables and drug wastage, for the different administration routes. Quantification of HCP and patient times, and utilization of resources will be calculated from cycles 2 to 7 of adjuvant treatment. In subsequent cycles, patients will continue PH FDC SC Q3W up to a total of 18 cycles (including neoadjuvant anti-HER2 treatment cycles) unless they choose to switch back to IV formulations. Time will be disaggregated per pre-specified tasks and per HCP. Patient chair time and treatment-room time will be assessed. Trained staff observers will conduct time measurements using a stopwatch, interview patients to determine hospital time, and record predictors of activity time. This study is registered at EudraCT 2020-004241-36. Citation Format: Joaquín Gavilá Gregori, Elena López Miranda, Santiago Escrivá-de-Romaní, Begoña Jiménez Rodríguez, Silvia Antolín Novoa, Luis Fernández Morales, Elena Galve Calvo, Lucía González Cortijo, Antonia Perelló Martorell, Julián Lagunar Ruiz, Santiago González Santiago. Time and motion study of a subcutaneous fixed-dose combination of pertuzumab and trastuzumab for the treatment of patients with HER2-positive early breast cancer (PHaTiMa) [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr OT1-12-09.

Utilization of Process Improvement Methodologies to Optimize Simulation Operations

Lean and Six Sigma methodologies provide tools for process evaluation and improvement. Baseline operational metrics of the simulation process at a high-volume academic center were defined and recommendations for an optimized future state were developed. The purpose of the current project is to report results of pilot studies conducted under the optimized future state.Patients were prospectively tracked from arrival through simulation completion to determine operational metrics associated with pilot studies. The simulation schedule was adjusted to include three patients in two-hour time blocks rather than one patient every hour to reduce dependence on upstream activities, including patient arrival, consent, and IV placement. One person was assigned to facilitate patient transfer through pre-simulation processes. Patients were brought to the simulation suite upon completion of upstream processes to reduce transition time. Start-to-end and start-to-start cycle times were defined as the total patient time in the simulation suite and the time between consecutive patients entering the simulation suite, including pre-simulation processes, respectively. Transition time was defined as non-value-added time between patients when the suite was not operational. Utilization was calculated by dividing machine uptime, defined as the time a patient is on the simulation table, by total time monitored. Baseline operational metrics were determined during a prior study. Statistical analysis was performed using Minitab v19.2. Of note, for the purpose of utilization and start-to-start cycle time comparisons, baseline metrics did not include downtime associated with lunch.Results of baseline and pilot metrics are based on 19 patients tracked in February 2020 and 17 patients tracked in October and November 2020, respectively. Start-to-end cycle times were similar in both baseline and pilot studies at 31 ± 15 and 30 ± 11 minutes, P = 0.833. Start-to-start cycle times were reduced during pilot studies from 57 ± 26 to 40 ± 12 minutes, P = 0.041, primarily driven by improvements in transition time, which was reduced from 27 ± 28 to 7 ± 5 minutes, P = 0.016. As a result, machine utilization was improved from 52.8 ± 3.4 to 73.7 ± 2.9%, P = 0.0004.Initial analysis of baseline metrics noted significant delay associated with pre-simulation processes with recommendation to de-couple operations where possible. The combination of an adjusted arrival schedule and addition of a person to facilitate patient movement resulted in significant improvements in transition time and utilization. During the pilot study, the optimized process was able to complete three patients in a two-hour block with no difficulty noted and the person responsible for patient movement had time available for additional responsibilities. Next steps include extended pilot studies with plans for utilizing off-line immobilization set-up to reduce start-to-end cycle times.

How Time Spent on Rituximab Infusion Impacts Patient Satisfaction, Stress, Employment, and Caregiver Burden

Background: Rituximab is used for treatment of follicular lymphoma (FL), diffuse large B-cell lymphoma (DLBCL), and chronic lymphocytic leukemia (CLL). A subcutaneous (SC) formulation (Rituxan Hycela™) has recently received FDA approval in the US. Understanding the patient perspective regarding rituximab administration is important as stakeholders make decisions between intravenous (IV) and SC methods of administration. Time for rituximab infusion impacts healthcare team resourcing including chair time and is a burden to patients receiving care at US cancer centers, and their caregivers. This study reports findings on patient-reported impact, as well as the detailed observation of time required for routine IV rituximab infusions in a community oncology setting. Results of this study will lay the groundwork for future comparison with similar data from SC administration upon its availability for use in the US.Methods: This prospective, observational, time and motion study was conducted in a single US community oncology practice. The sample size for this study was selected in light of case availability and the descriptive aims of the project. Patients were required to be treated with IV rituximab for DLBCL (1st-line), FL or CLL (any line). Direct patient observations and surveys took place from 4/27/2017 to 6/26/2017. Time and motion methodology (continuous recording and momentary time sampling) was used to document detailed time required for various steps of the infusion process (time in waiting room, chair time, time for pre-med, etc.), and for various stakeholders (patient, practitioner, pharmacist, etc.). Additionally, a 19-item patient survey instrument was administered to evaluate patient-reported impact of infusion-visit time on various domains including stress, employment, caregiving, and work-related responsibilities.Results: The study included 40 patients (median age, 69 years; range 34-88 years). Of these, 29 (72.5%) were male, 34 (85.0%) white, and 6 (15.0%) African American. The most common qualifying diagnosis was FL (47.5%) followed by DLBCL (40.0%) and CLL (12.5%). Five patients had documented ECOG status of ≥2. Of the 25 patients who received rituximab in 1st-line therapy, most (56.0%) were infused with rituximab, cyclophosphamide, doxorubicin, and vincristine. Mean observed total patient time at the infusion center was 319 minutes (SD 95). Of that, the mean time patients spent in the infusion chair was 212 minutes (SD 64) . On infusion day, 35% of patients reported feeling somewhat or extremely stressed, 50% were neutral, while 15% were somewhat or extremely unstressed. Most patients (75%) indicated that reducing chair time by a couple of hours would have a moderate or major positive impact on their infusion day. Patients were generally satisfied (60% somewhat or extremely satisfied, 15% neutral) with wait times before receiving their infusion. The majority (70%) reported usual wait times of 15-60 minutes; however, 25% reported usual wait times of over 60 minutes. There were 7 patients (17.5%) who reported that their employment status changed due to their cancer diagnosis. Of the patients who worked, all had to miss work for every infusion. A caregiver was required for 32.5% of patients, and these caregivers all accompanied the patients on infusion day. Of those caregivers, 38% had to miss work to accompany the patient to their infusion.Conclusions: This real-world, single-center observational community oncology study shows the detailed time burden of IV rituximab administration, and provides the patient perspective. Detailed time required for each step of the administration was recorded, including a mean patient time of over 5 hours at the infusion center per visit. Many patients reported being stressed by their infusion visit, and most patients reported that reduction in time required for receiving their therapy would have a positive impact. Understanding specific details regarding the burden of administration for rituximab, including the patient-reported perspective, is an important aspect for informed clinical decision making and improving quality of care. DisclosuresFisher:Vector Oncology: Employment. Wallick:Genentech: Employment. Miller:Vector Oncology: Employment. Walker:Vector Oncology: Employment. Lash:Genentech: Employment. Dawson:Genentech: Employment, Equity Ownership. Reyes:Genentech Inc.: Employment, Equity Ownership.

Comparing Plastic Surgeon Operative Time for DIEP Flap Breast Reconstruction: 2-stage More Efficient than 1-stage?

Background:The deep inferior epigastric perforator flap for breast reconstruction is associated with lengthy operative times that remain an issue for plastic surgeons today. The main objective of this study was to determine if a 2-stage deep inferior epigastric perforator flap reconstruction resulted in a shorter total plastic surgeon operative time compared with an immediate reconstruction.Methods:A retrospective chart review was conducted on all patients who underwent deep inferior epigastric perforator flap breast reconstruction from February 2013 to July 2020 by the senior author. Patient demographics, medical comorbidities, mastectomy characteristics, expander placement, reconstructive procedures, operative time, and complications were tabulated.Results:The study included a total of 128 patients. For immediate/1-stage flap reconstruction, average operative times for the plastic surgeon were 427.0 minutes for unilateral procedures, and 506.3 minutes for bilateral procedures. For delayed/2-stage reconstruction, average combined plastic surgeon operative times were 351.1 minutes for unilateral expander followed by flap reconstruction (75.9 minutes shorter than immediate unilateral, P = 0.007), and 464.8 minutes for bilateral reconstruction (41.5 minutes shorter than immediate bilateral, P = 0.04). Total patient time under anesthesia was longer for 2-staged bilateral reconstruction (P = 0.0001), but did not differ significantly for unilateral reconstruction. Complications between immediate and delayed groups were not significantly different.Conclusions:We found that staged reconstruction over 2 procedures resulted in a significant reduction in operative time for the plastic surgeon for both unilateral and bilateral reconstruction. With amenable breast surgeons and patients, the advantages of controlling scheduling and the operating room may encourage plastic surgeons to consider performing free flap reconstruction in a delayed fashion.

Factors associated with time to first analgesic medication in the emergency department.

To examine the factors associated with time to first analgesic medication in the emergency department. Pain is the most common symptom presenting to the emergency department, and the time taken to deliver analgesic medication is a common outcome measure. Factors associated with time to first analgesic medication are likely to be multifaceted, but currently poorly described. Retrospective cohort study. Cox proportional hazards regression modelling was undertaken to evaluate the associations between person, environment, health and illness variables within Symptom Management Theory and time to first analgesic medication in a sample of adult patients presenting with moderate-to-severe pain to an emergency department over twelve months. This study was completed in line with the STROBE statement. 383 patients were included in the study, 290 (75.92%) of these patients received an analgesic medication in a median time of 45 minutes (interquartile range, 70 minutes). A model containing nine explanatory variables associated with time to first analgesic medication was identified. These nine variables (employment status, discharge location, triage score, Charlson score, arrival pain score, socio-economic status, first location, daily total treatment time and patient time to be seen) represent all of the domains of the Symptom Management Theory. Person, environment, health and illness factors are associated with the time taken to deliver analgesic medication to those in pain in the emergency department. This study demonstrates the complexity of factors associated with pain care and the applicability of Symptom Management Theory to pain care in the emergency department. Identifying a model of factors that are associated with the time in which the most common symptom presenting to the emergency department is treated allows for targeted interventions to groups likely to receive poor care and a framework for its evaluation.

Minimally Invasive Surgery for Anterior Pubic Rami Fractures Under Fluoro-Navigation Using the Medtronic O Arm System and Calcium Phosphate for Internal Fixation

Introduction: The incidence of anterior pubic rami fractures in elderly female patients over the age of 65 has been reported to be 64 %. Osteoporosis plays a role with these fractures, as they are caused by minimal low energy injuries from a fall. Indications for internal fixation of anterior pelvic ring are controversial because of the etiology being low energy trauma and the location being a non-weight bearing surface. In contrast to conventional open pelvic surgery, percutaneous screw fixation has gained popularity in the treatment of pelvic fractures, mainly because of minimal soft tissue damage, less operative blood loss, early surgical intervention, and comfortable mobilization of the patient. The use of calcium phosphate as a form of internal fixation further advances the advantages of minimally invasive surgery for internal fixation with less morbidity by the use of screw fixation. The incorporation of fluoro-navigation is a new surgical technique in orthopedic trauma surgery. (Figure 1) This study is to report our clinical results of fluoro-navigation surgery in anterior pelvic pubic rami fractures using calcium phosphate as the fixation of choice. This is the first report of this method of treatment using a new combination of visualization and internal fixation. Materials and Methods: From April 2018 to December 2019, 30 patients with anterior pubic rami fractures were treated with percutaneous cannulated calcium phosphate delivery under Medtronic O arm (fluoro-navigation) control. There were 5 male and 25 females, with a mean age of 84.6 years (range 80-104) for females and mean age of 90 years (84 – 99) for the 5 males. According to the AO and Orthopedic Trauma Association classification, all were considered lateral compression types of fractures. All patients were operated on when their general medical condition stabilized after emergency management and admission. The pain score on admission was reported as 10/10 in all cases. Plain standard pelvic x-rays were obtained on admission as well as CT scans of the pelvis. All the anterior pubic rami fractures were fixed using percutaneous delivery of calcium phosphate with the Zimmer trocar system by one senior surgeon. The Medtronics O arm fluoro-navigation was used in all cases. The surgeon was familiar with the navigation system and had much experience in the computer-assisted percutaneous placement of the trocars. Results: A total of 30 patients were treated with this new combination of surgical treatment of anterior pubic rami fractures. No screws were inserted or found to be necessary for fracture treatment. Each case used 2 trocars from the kits supplied from Zimmer. One end delivery trocar was directed to the inferior pubic ramus fracture and the second which was a side delivery trocar was used for the superior pubic ramus fracture. A total of 10 cc of calcium phosphate was used in each case, 5 cc per trocar. The position of the trocars were placed using the fluoro-navigation control of the O arm. Once the trocars were properly placed the calcium phosphate was delivered and viewed under flouro control and then again viewed with the spin sequence using the Medtronics O arm. Total patient time in the operating room was 56 minutes; Total surgery time was 26 minutes. Anesthesia in most cases was MAC or light sedation with local skin infiltration using 1% lidocaine. Blood loss during the operation was considered very minimal with derma bond used to cover the percutaneous sites as well as a small band-aid. No superficial or deep infections occurred. No patient sustained recognized neurologic, vascular, or urologic injury because of the percutaneous pubic rami fixation with calcium phosphate. Extravasation of the calcium phosphate from the fracture’s sites did not pose any sequelae with soft tissue injury or with fracture healing. All patients were encouraged to get out of bed and weight bear according to comfort on post-op day 1. All fractures united at the last follow-up. Conclusions: This study presented for the first time two new techniques for the operative treatment of pubic rami fractures of the pelvis. The delivery of calcium phosphate for fracture fixation of pubic rami fractures has been found to be safe, minimally invasive, providing pain relief and stability permitting early mobilization. The addition of intra-operative fluoro- navigation technique makes the fracture treatment an accurate, and rapid method for the treatment of pubic rami fractures. Consistency of the operative procedure and teaching are mandatory for the success of this procedure. The learning curve for most orthopedists should be very short. The outcomes have been shown to benefit patient mobilization, decrease morbidity and decrease hospital stay

Utilization of Lean and Six Sigma Methodologies to Characterize and Optimize Simulation Throughput

Process improvement methodologies, including Lean and Six Sigma, enable evaluation of critical operations. The current simulation process utilizes a single simulator to support four Linac and brachytherapy operations. It is hypothesized that improving inefficiencies in patient and information flow would significantly improve throughput. We sought to define baseline operational cycle times, throughput and develop solutions associated with an optimized future state. Ninety-four patients simulated in January 2020 were retrospectively evaluated to determine simulation-specific metrics including throughput, utilization, and the percentage of patients traveling greater than 50 miles that were simulated on the same day as consult. Throughput was defined as the number of patients simulated per day. Utilization was calculated by dividing machine uptime, defined as the time a patient is on the simulation table, by total time monitored. Additionally, 19 patients in February 2020 were tracked prospectively from clinic arrival through simulation completion to quantify operational cycle times and note process delays. Start-to-end and start-to-start cycle times were defined as the total patient time in the simulation suite and the time between consecutive patients entering the simulation suite, including pre-simulation processes, respectively. Immobilization cycle time was defined as the time required to create the immobilization device. Baseline simulation throughput was calculated at 7.2 ± 1.9 patients per day. Utilization was calculated at 46.7 ± 1.6% with a start-to-end cycle time of 0.5 ± 0.2 hours. The calculated start-to-start cycle time demonstrated increased magnitude and variability at 1.1 ± 0.8 hours. During retrospective evaluation it was noted that 37.2% of patients checked in late with an average of 0.8-hour delay. Patients seen in consult traveling from greater than 50 miles away achieved 37.5% same-day simulation. Immobilization cycle time was calculated at 0.2 ± 0.0 hours. The current-state simulation process is highly dependent on serial completion of pre-simulation activities. It is recommended to decouple these processes from simulation where possible. First, it is recommended to divide the day into two-hour time blocks with three patients scheduled per block to reduce dependence on patient arrival time and pre-simulation processes. Additionally, making immobilization devices off-line prior to patient placement on the simulation table would decrease start-to-end cycle time and improve throughput. Finally, improved communication associated with patient preparation would potentially decrease non-value-added wait times associated with bladder filling or oral contrast administration. Future directions include piloting the proposed solutions, conservatively estimated to result in throughput of 10-12 patients per day, which represents an estimated 40 to 65% improvement over current baseline.

Appointment scheduling at a multidisciplinary outpatient clinic using stochastic programming

AbstractThe purpose of this paper is to investigate the problem of constructing an appointment template for scheduling patients at a specific type of multidisciplinary outpatient clinic called an integrated practice unit (IPU). The focus is on developing and solving a stochastic optimization model for a back pain IPU in the face of random arrivals, an uncertain patient mix, and variable service times. The deterministic version of the problem is modeled as a mixed integer program with the objective of minimizing a weighted combination of clinic closing time (duration) and total patient waiting time (length of stay). A two‐stage stochastic program is then derived to account for the randomness and the sequential nature of the decisions. Although it was not possible to solve the two‐stage problem for even a limited number of scenarios, the wait‐and‐see (WS) problem was sufficiently tractable to provide a lower bound on the stochastic solution. The introduction of valid inequalities, limiting indices, and the use of special ordered sets helped to speed up the computations. A greedy heuristic was also developed to obtain solutions much more quickly. Out of practical considerations, it was necessary to develop appointment templates with time slots at fixed intervals, which are not available from the WS solution. The first to be derived was the expected value (EV) template that is used to find the expected value of the EV solution (EEV). This solution provides an upper bound on the objective function value of the two‐stage stochastic program. The average gap between the EEV and WS solutions was 18%. Results from extensive computational testing are presented for the EV template and for our adaptation of three other templates found in the literature. Depending on the relative importance of the two objective function metrics, the results demonstrate the trade‐off that exists between them. For the templates investigated, the “closing time” ranged from an average of 235 to 275 minutes for a 300‐minute session, while the corresponding “total patient time in clinic” ranged from 80 to 71 minutes.

Time and motion study of pharmacist prescribing of oral hormonal contraceptives in Oregon community pharmacies

ObjectivesThe aim of this time and motion study was to evaluate the procedural time and steps of performing an oral hormonal contraceptive pharmacist prescribing service in an Oregon community pharmacy. MethodsA standardized patient seeking oral hormonal contraception visited 13 community pharmacies throughout February 2018 in the tri-county Portland, Oregon, metropolitan area for pharmacist-prescribed hormonal contraception services for a total of 26 patient encounters. An observer was present at each encounter to record the time for each step and the total encounter time. Each pharmacist was asked to perform assessment procedures and prescribing for each of 2 standardized patient presentations: in cohort 1 (n = 13), the pharmacist’s assessment resulted in a hormonal contraception prescription written; in cohort 2 (n = 13), pharmacist’s assessment detected contraindications and resulted in a medical referral to another health care prescriber. ResultsThe average total patient time from arrival at the pharmacy to the generation of either a written prescription for hormonal contraception or referral to another health care provider was 17.9 and 14.1 minutes, respectively. Without accounting for documentation or dispensing the prescription, the average total pharmacist time to perform the service and issue a prescription, or refer the patient, was 7.8 and 5.4 minutes, respectively. ConclusionThe results indicate that the pharmacist prescribing service for oral hormonal contraception requires a modest amount of pharmacist time. Incorporation of practice into regular workflow appears to have an impact similar to other clinical services, such as immunizations and point-of-care testing. The patient time spent with the pharmacist was similar to other health care provider visits.

Clinical Care Redesign to Improve Value in Carpal Tunnel Syndrome: A Before-and-After Implementation Study.

Carpal tunnel surgery is one of the most common procedures completed on the upper limb in the United States. There is currently no evidence-based high-value clinical care pathway to inform the management of carpal tunnel syndrome (CTS). We created an evidence-based care pathway and implemented a quality improvement initiative to evaluate its effect on patient time, quality, and cost in a tertiary care ambulatory surgery center. We developed a high-value clinical care pathway for CTS and implemented the intraoperative phase of the pathway. This included (1) implementing an evidence-based protocol for wide-awake local anesthesia, (2) removing non-value-added processes of care, and (3) implementing educational sessions with surgery staff regarding the initiative. We prospectively collected data on patient time, visual analog scale pain scores (quality), and percent change in total direct costs of the intraoperative phase of care (cost). A total of 50 patients were included in this implementation study: 30 prior to implementation of the intervention and 20 after. There was a significant decrease in average patient wheels in to surgery time, postanesthesia care unit to discharge time, and total patient time (lead time). There was no difference in preoperative or postoperative pain before and after the intervention. There was a 31% reduction in total direct costs. Implementing the intraoperative phase of this clinical care pathway with wide-awake surgery can reduce patient lead time, maintain quality, and reduce total direct costs in an ambulatory surgery center. Quality improvement interventions, such as the implementation of an evidence-based clinical care pathway for the treatment for CTS, may improve value to health systems.