Consult Volume Research Articles

Improving Timeliness of Internal Medicine Consults in the Emergency Department: A Quality Improvement Initiative.

Emergency department (ED) wait time is an important health system quality indicator. Prolonged consult to decision time (CTDT), the time it takes to reach a disposition decision after receiving a specialty consultation request, can contribute to increased overall length of stay in the ED. To identify delays in the consultation process for general internal medicine (GIM) and trial interventions to reduce CTDT. The study was conducted at a large tertiary teaching hospital with GIM inpatient wards at two campuses. Four interventions were trialed over sequential Plan-Do-Study-Act cycles: (1) process mapping, (2) resident education sessions, (3) audit and feedback of CTDT, and (4) adding a swing shift during peak consult volume. The primary outcome measures were mean CTDT for patients admitted to GIM and the proportion of admitted patients with CTDT of less than 3 hours. Mean CTDT decreased from 4.61 hours before intervention to 4.18 hours after intervention (p < .0001). The proportion of GIM patients with CTDT less than 3 hours increased from 25% to 33% (p < .0001). The interventions trialed led to a sustained reduction in CTDT over a 12-month period and demonstrated the effectiveness of education in influencing physician performance.

Demonstrating Value Through Tracking Ethics Program Activities Beyond Ethics Consultations

Demonstrating value is an ongoing process and requirement for institutional survival for ethics programs. Although our ethics program has significantly increased our ethics consultation volume and maintains a robust database that tracks ethics consultation data, these data regarding ethics consultations alone do not accurately represent the program's overall activities and value to the institution. The roles and responsibilities of clinical ethicists extend beyond clinical ethics consultation, and there are many other ways that clinical ethicists contribute and add value to their institutions. This article describes our ethics program's early efforts to systematically track ethics program activities outside of ethics consultations as a way to demonstrate additional value to the institution that goes beyond ethics consultation. By systematically tracking activities such as internal ethics education sessions, conference presentations, publications, grants, committee/policy work, and other activities, our ethics program has been able to gather substantial quantitative data that highlight our program's numerous activities and outreach, both within and outside the institution, that provide additional value to the institution beyond our ethical consultation activities.

COVID-19 Pandemic Significantly Decreases Acute Surgical Complaints.

The coronavirus disease 2019 (COVID-19) pandemic significantly reduced elective surgery in the United States, but the impact of COVID-19 on acute surgical complaints and acute care surgery is unknown. A retrospective review was performed of all surgical consults at the Hospital of the University of Pennsylvania in the 30 days prior to and 30 days following confirmation of the first COVID-19 patient at the institution. Consults to all divisions within general surgery were included. Total surgical consult volume decreased by 43% in the post-COVID-19 period, with a significant reduction in the median daily consult volume from 14 to 8 (P < .0001). Changes in consult volume by patient location, chief complaint, and surgical division were variable, in aggregate reflecting a disproportionate decrease among less acute surgical complaints. The percentage of consults resulting in surgical intervention remained equal in the 2 periods (31% vs 28%, odds ratio 0.85, 95% CI 0.61-1.21, P = .38) with most but not all operation types decreasing in frequency. The rise in the COVID-19 inpatient census led to increased consultation for vascular access, accommodated at our center by the creation of a new surgical procedures team. The COVID-19 pandemic significantly altered the landscape of acute surgical complaints at our large academic hospital. An appreciation of these trends may be helpful to other Departments of Surgery around the country as they deploy staff and allocate resources in the COVID-19 era.

Effect of a free healthcare policy on health services utilisation for non‐malarial febrile illness by children under five years in Burkina Faso: an interrupted time series analysis

To assess the effect of a free healthcare policy for children under five years old implemented in Burkina Faso since April 2016, on the use of health care of non-malarial febrile illnesses (NMFI). To assess the immediate and long-term effect of the free healthcare policy in place, we conducted an interrupted time series analysis of routinely collected data on febrile illnesses from three urban primary health centres of Ouagadougou between 1 January 2015 and 31 December 2016. Of the 39046 febrile cases reported in the study period, 17017 NMFI were included in the study. Compared to the period before the intervention, we observed an immediate, non-statistically significant increase of 7% in the number of NMFI (IRR=1.07; 95% CI=0.75, 1.51). Compared to the trend that would have been expected in absence of the intervention, the results showed a small but sustained increase of 6% in the trend of monthly number of NMFI during the intervention period (IRR=1.06; 95%CI=1.01, 1.12). Our study highlighted an increase in the uptake of healthcare services, specifically for NMFI by children under five years of age, after the implementation of a free care policy. This analysis contributes to informing decision makers on the need to strengthen the capacities of healthcare centres and to anticipate the challenges of the sustainability of this policy.

Causal Effect of Honorary Titles on Physicians' Service Volumes in Online Health Communities: Retrospective Study.

BackgroundAn OHC online health community (OHC) is an interactive platform for virtual communication between patients and physicians. Patients can typically search, seek, and share their experience and rate physicians, who may be involved in giving advice. Some OHC providers provide incentives in form of honorary titles to encourage the web-based involvement of physicians, but it is unclear whether the award of honorary titles has an impact on their consultation volume in an OHC.ObjectiveThis study is designed to identify the differential treatment effect of the incentive policy on the service volumes for the subgroups of treatment and control in an OHC. This study aims to answer the following questions: Does an honorary title for physicians impact their service volumes in an OHC? During the period of discontinuity, can we identify the sharp effect of the incentive award on the outcomes of physicians’ service volumes?MethodsWe acquired the targeted samples based on treatment, namely, physicians with an honorary title or not and outcomes measured before and after the award of the 2 subgroups. A regression discontinuity design was applied to investigate the impact of the honorary titles incentive as a treatment in an OHC. There was a sharply discontinuous effect of treatment on physicians’ online health service performance. The experimental data set consisted of 346 physicians in the treatment group (with honorary titles). Applying the propensity score matching method, the same size of physicians (n=346) was matched and selected as the control group.ResultsA sharp discontinuity was found at the time of the physician receiving the honorary title. The results showed that the parametric estimates of the coefficient were significantly positively (P<.001) associated with monthly home page views. The jump in the monthly volumes of home page views was much sharper than that of the monthly consultations.ConclusionsThe changes in the volumes of monthly consultations and home page views reflect the differential treatment effect of honorary titles on physicians’ service volumes. The effect of the incentive policy with honorary titles is objectively estimated from both the perspective of online and offline medical services in an OHC. Being named with honorary titles significantly multiplied monthly home page views, yet it did not significantly impact monthly consultations. This may be because consultation capacity is limited by the physician's schedule for consultations.

Defining the volume of consultations for musculoskeletal infection encountered by pediatric orthopaedic services in the United States

ObjectiveAdequate resources are required to rapidly diagnose and treat pediatric musculoskeletal infection (MSKI). The workload MSKI consults contribute to pediatric orthopaedic services is unknown as prior epidemiologic studies are variable and negative work-ups are not included in national discharge databases. The hypothesis was tested that MSKI consults constitute a substantial volume of total consultations for pediatric orthopaedic services across the United States.Study designEighteen institutions from the Children’s ORthopaedic Trauma and Infection Consortium for Evidence-based Study (CORTICES) group retrospectively reviewed a minimum of 1 year of hospital data, reporting the total number of surgeons, total consultations, and MSKI-related consultations. Consultations were classified by the location of consultation (emergency department or inpatient). Culture positivity rate and pathogens were also reported.Results87,449 total orthopaedic consultations and 7,814 MSKI-related consultations performed by 229 pediatric orthopaedic surgeons were reviewed. There was an average of 13 orthopaedic surgeons per site each performing an average of 154 consultations per year. On average, 9% of consultations were MSKI related and 37% of these consults yielded positive cultures. Finally, a weak inverse monotonic relationship was noted between percent culture positivity and percent of total orthopedic consults for MSKI.ConclusionAt large, academic pediatric tertiary care centers, pediatric orthopaedic services consult on an average of ~3,000 ‘rule-out’ MSKI cases annually. These patients account for nearly 1 in 10 orthopaedic consultations, of which 1 in 3 are culture positive. Considering that 2 in 3 consultations were culture negative, estimating resources required for pediatric orthopaedic consult services to work up and treat children based on culture positive administrative discharge data underestimates clinical need. Finally, ascertainment bias must be considered when comparing differences in culture rates from different institution’s pediatric orthopaedics services, given the variability in when orthopaedic physicians become involved in a MSKI workup.

Answering the Call for Standardized Reporting of Clinical Ethics Consultation Data

Benchmarks against which healthcare ethics consultation (HCEC) services can assess their performance are needed. As first-generation benchmarks continue to be developed, it is the obligation of the field to continually evaluate how these measures reflect the performance of any single HCEC service. This will be possible only with widespread reporting of standardized data points. In their article in this issue of The Journal of Clinical Ethics, Glover and colleagues provide a valuable preliminary approach for assessing appropriate consult volumes for a HCEC service. The limitations of their study read as a call to action for the field of clinical ethics to expand and standardize data reporting so that more robust metrics can be developed. In response to this call by Glover and colleagues, the Cleveland Clinic HCEC service provides consult data from 2015 through 2019 for one of its medical centers, and offers an additional volume-based metric, consult-to-ICU-to-bed ratio (CiBR), that may add nuance to any normative assessment of HCEC service consult volume. Given that volume-based metrics are the native language of the clinical environment, efforts to improve such metrics in the field through transparency and standardization are warranted. However, the expositive power of volume- based metrics is limited; additional domains related to quality and outcomes are needed.

Estimating the Financial Impact of Site-Neutral Payments for Outpatient Consultations in Oral and Maxillofacial Surgery

Estimating the Financial Impact of Site-Neutral Payments for Outpatient Consultations in Oral and Maxillofacial Surgery

Integration of a proactive, multidisciplinary mental health team on hospital medicine improves provider and nursing satisfaction

ObjectivePsychiatric comorbidity among hospital medicine patients is common and often complicates care delivery and compromises outcomes. Team-based, proactive consultation–liaison (CL) psychiatry has been shown to reduce hospital length of stay (LOS) and care costs, but staff satisfaction with this model has not been explored in detail. Here we evaluate its impact on hospital medicine provider and nurse satisfaction. MethodsWe implemented a team-based proactive CL service that reviews all admitted hospital medicine patients across 3 units for psychiatric comorbidity and provides unit-wide integrated mental health care. Hospital medicine staff completed surveys before and after a 6-month pilot phase: 10-item provider surveys covered resource adequacy, safety, time for healthcare improvements, and burnout; 26-item nurse surveys included the same 10 items plus 8 on behavioral health assessment competency and 8 on intervention competency. Additionally, we characterized psychiatric comorbidity, calculated consultation latency and volume and also average LOS during these 6 months. ResultsThe provider response rate was 57% (20/35 before; 21/37 after) and roughly a third for nurses (32/~90 and 31/~90, respectively). Providers rated 9 of 10 items as improved, including one on burnout. Nursing satisfaction improved similarly but with lower effect sizes. During the pilot (n = 1590), 71% had chart-identified psychiatric comorbidity. Consultation latency decreased by 0.86 days; consultation rate increased nearly 3-fold; and average LOS decreased by 0.33 days. ConclusionsTeam-based proactive CL psychiatry enhances provider and nurse satisfaction and may even reduce provider burnout. We also confirmed that this model is associated with reduced average LOS.

Benefits of High-Volume Medical Oncology Care for Noncurable Pancreatic Adenocarcinoma: A Population-Based Analysis.

Although pancreatic adenocarcinoma (PA) surgery performed by high-volume (HV) providers yields better outcomes, volume-outcome relationships are unknown for medical oncologists. This study examined variation in practice and outcomes in noncurative management of PA based on medical oncology provider volume. This population-based cohort study linked administrative healthcare datasets and included nonresected PA from 2005 through 2016. The volume of PA consultations per medical oncology provider per year was divided into quintiles, with HV providers (≥16 patients/year) constituting the fifth quintile and low-volume (LV) providers the first to fourth quintiles. Outcomes were receipt of chemotherapy and overall survival (OS). The Brown-Forsythe-Levene (BFL) test for equality of variances was performed to assess outcome variability between provider-volume quintiles. Multivariate regression models were used to examine the association between management by HV provider and outcomes. A total of 7,062 patients with noncurable PA consulted with medical oncology providers. Variability was seen in receipt of chemotherapy and median survival based on provider volume (BFL, P<.001 for both), with superior 1-year OS for HV providers (30.1%; 95% CI, 27.7%-32.4%) compared with LV providers (19.7%; 95% CI, 18.5%-20.6%) (P<.001). After adjustment for age at diagnosis, sex, comorbidity burden, rural residence, income, and diagnosis period, HV provider care was independently associated with higher odds of receiving chemotherapy (odds ratio, 1.19; 95% CI, 1.05-1.34) and with superior OS (hazard ratio, 0.79; 95% CI, 0.74-0.84). Significant variation was seen in noncurative management and outcomes of PA based on provider volume, with management by an HV provider being independently associated with superior OS and higher odds of receiving chemotherapy. This information is important to inform disease care pathways and care organization. Cancer care systems could consider increasing the number of HV providers to reduce variation and improve outcomes.

Abstract TP311: Organizational Culture Drives Confidence in Implementing Telestroke Care

Background: In its first 18 months, the VA National Telestroke Program (NTSP) conducted 800 consults at 30 sites. Data from staff at participating sites are collected in anonymous surveys. We aimed to determine factors associated with confidence in providing stroke care at these sites, and whether confidence is associated with performance on NTSP quality indicators. Methods: Surveys were sent to providers at participating sites at baseline (BL) and 6 - 12 months post-NTSP implementation (post-I). Survey questions included items about confidence providing stroke care and items from the Organizational Readiness to Change Assessment (ORCA). Confidence (0-10) was dichotomized into fully confident (mean score of 10) and not fully confident sites (mean &lt;10). ORCA score was averaged by site. Covariates included site performance, volume, and time in the NTSP. We used a Kruskal Wallis analysis to examine the association of BL variables with post-I confidence, and a Pearson correlation test to examine the association between performance indicators and confidence. Results: 16 sites, with 54 staff members total responding (57% nurses, 26% providers, 17% administrators/other), had BL and post-I data. Five sites were fully confident at the post-I assessment, the remaining 11 had mean confidence scores 8.32 - 9.5. Site confidence improved over time (mean 7.97 at BL vs. 9.44 post-I, p = 0.004), but confidence was not associated with site performance on any NTSP indicator. Higher ORCA scores were significantly associated with post-I confidence (mean ORCA 4.46 vs. 4.01, p=0.04). Fully confident sites also had shorter NTSP participation times (mean 5.40 months in the fully confident sites vs. 13.45, P=0.01). BL confidence, rurality, and consultation volume were not associated with post-I confidence. Periodic retraining was the most commonly suggested program addition. Conclusions: Organizational culture, but not performance or consult volume, is significantly associated with staff confidence in providing stroke care via telestroke. The finding that less confident sites have longer participation times suggests that planned retraining should be a part of telestroke programs to help sustain site confidence in providing stroke care.

Abstract WP299: Current Trends in Telestroke Utilization by Spoke Sites Using Distributed Provider Service Organizations via a Commercial Vendor Platform: Data From 2013 to 2019

Background: Most data on telestroke utilization come from single academic hub-and-spoke telestroke networks. Our objective was to describe trends in telestroke consultations among a national sample of telestroke sites using a common commercial vendor platform. Methods: A major commercial telestroke vendor (InTouch Health) provided data on all telestroke consultations by two provider service organizations from 2013-2019. Kendall’s τ β nonparametric test was utilized to assess time trends and generalized linear models assessed the link between hospital consult utilization and alteplase (tPA) performance adjusting for hospital characteristics. Results: Among 67,736 telestroke consultations to 132 spoke sites, most occurred in the emergency department (90%) and for stroke indications (TIA 13%, ischemic stroke (IS) 39%, hemorrhagic stroke 2%, other 46%).Median NIHSS was low (2 (IQR 0-6). tPA was recommended for 23% of IS patients. From 2013 to 2019, times from ED arrival to NIHSS, CT scan, imaging review, consult, and tPA administration all decreased (p&lt;0.05 for all), while times from consult start to tPA recommendation and bolus increased (p&lt;0.01 for both). Transfer was recommended for 8% of IS patients diagnosed. Number of patients treated with tPA per hospital was significantly associated with number of consults, size and US region in unadjusted and adjusted analyses (Table). After accounting for hospital characteristics, only duration of hospital participation in the network was associated with shorter hospital median door-to-needle time for tPA delivery (39 minutes shorter per year, p=0.04). Conclusion: In this network, times to consult start and tPA bolus decreased over time, though performance varied by telestroke consult volume and region. Duration of telestroke participation was associated with faster tPA delivery, suggesting practice improves performance. Commercial telestroke networks appear to behave similarly to academic networks.

Hip Fracture Volume Does Not Change at a New York City Level 1 Trauma Center During a Period of Social Distancing.

Purpose:To characterize the volume and variation in orthopedic consults and surgeries that took place during a period of social distancing and pandemic.Methods:All orthopedic consults and surgeries at an urban level 1 trauma center from 3/22/20-4/30/2020 were retrospectively reviewed (the social distancing period). Data from the same dates in 2019 were reviewed for comparison. Age, gender, Score for Trauma Triage in the Geriatric and Middle Aged (STTGMA) score and injury type were queried. Operating room data collected included: type of surgery performed, inpatient or outpatient status, and if the cases were categorized as elective, trauma or infectious cases.Results:Compared to 2019, there was a 48.3% decrease in consult volume in 2020. The 2020 population was significantly older (44.0 vs 52.6 years-old, p = 0.001) and more male (65% vs 35%, p = 0.021). There were 23 COVID positive patients, 10 of which died within the collection period. Consult distribution dramatically changed, with decreases in ankle fractures, distal radius fractures and proximal humerus fractures of 76.5%, 77.4% and 55.0%, respectively. However, there was no significant difference in volume of hip, tibial shaft and femoral shaft fractures (p > 0.05). In 2020, there was a 41.4% decrease in operating room volume, no elective cases were performed, and cases were primarily trauma related.Conclusions:During a period of pandemic and social distancing, the overall volume of orthopedic consults and surgeries significantly declined. However, hip fracture volume remained unchanged. Patients presenting with orthopedic injuries were older, and at higher risk for inpatient mortality.

1092. Impact of Relieving Infectious Diseases Fellows from Off-Hour/Weekend Antimicrobial Stewardship Coverage

BackgroundAntimicrobial stewardship programs (ASPs) often utilize Infectious Diseases fellows (IDFs) to cover pre-authorization processes during evening and weekend hours. IDFs often provide ASP coverage in addition to their inpatient consult roles. In response to increasing consult volume, we worked with our fellowship program to relieve IDFs of evening and weekend coverage (a decrease in fellow coverage by 26 hours per week) starting in October 2017. Members of the ASP assumed the majority of these evening and weekend hours. Additional post-prescriptive activities and a rotation in Infection Control and Antimicrobial Stewardship were implemented in response. We sought to analyze the impact of this intervention.MethodsIntervention and medication data were extracted from the electronic medical record during 1 July 2017 through 30 September of 2017 (IDF Coverage) and the same 3 months of 2018 (ASP Coverage). Comparisons between the two periods were performed using descriptive statistics of the number of interventions, number of weekend interventions, types of interventions, and days of therapy (DOT; per 1000 patient-days).ResultsComparing July-September of 2017 and 2018, total ASP interventions increased 16% (1192 to 1391); weekend ASP interventions increased 75% (139 to 243). The most common interventions were “Choice of Therapy” (41% in both years), “De-Escalation” (17% in 2017, 16% in 2018), and “Dose/Interval Optimization” (10% in both years). The most intervened agents were piperacillin–tazobactam, cefepime, vancomycin, meropenem, and ceftazidime.Comparing the same time periods, total antibiotic DOT decreased 4% (714.1 to 684.9). There was a 28% decrease in piperacillin–tazobactam (41.47 to 29.85), 19% decrease in meropenem (28.08 to 22.61), and 7% decrease in vancomycin (125.09 to 116.17) use. Ceftazidime was unchanged (18.13 to 18.08). Cefepime increased by 9% (56.78 to 61.97).ConclusionRelieving IDFs of evening and weekend ASP coverage during busy inpatient consult rotations may help decrease burnout. The assumption of these hours by dedicated members of ASP led to an increase in documented total and weekend ASP interventions. In addition, the change was associated with a relative decrease in piperacillin–tazobactam, meropenem, and vancomycin use.Disclosures All authors: No reported disclosures.

Variation in receipt of therapy and survival with provider volume for medical oncology in non-curative esophago-gastric cancer: a population-based analysis.

While surgical care by high-volume providers for esophago-gastric cancer (EGC) yields better outcomes, volume-outcome relationships are unknown for systemic therapy. We examined receipt of therapy and outcomes in the non-curative management of EGC based on medical oncology provider volume. We conducted a population based retrospective cohort study of non-curative EGC over 2005-2017 by linking administrative healthcare datasets. The volume of new EGC consultations per medical oncology provider per year was calculated and divided into quintiles. High-volume (HV) medical oncologists were defined as the 4-5th quintiles. Outcomes were receipt of chemotherapy and overall survival (OS). Multivariate logistic and Cox-proportional hazards regressions examined the association between management by HV medical oncologist, receipt of systemic therapy, and OS. 7011 EGC patients with non-curative management consulted with medical oncology. 1-year OS was superior for HV medical oncologists (> 11 patients/year), with 28.4% (95% CI 26.7-30.2%) compared to 25.1% (95% CI 23.8-26.3%) for low volume (p < 0.001). After adjusting for age, sex, comorbidity burden, rurality, income quintile, and diagnosis year, HV medical oncologist was independently associated with higher odds of receiving chemotherapy (OR 1.13, 95% CI 1.01-1.26), and independently associated with superior OS (HR 0.89, 95% CI 0.84-0.93). Medical oncology provider volume was associated with variation in non-curative management and outcomes of EGC. Care by an HV medical oncologist was independently associated with higher odds of receiving chemotherapy and superior OS, after adjusting for case mix. This information is important to inform disease care pathways and care organization; an increase in the number of HV medical oncologists may reduce variation and improve outcomes.

Surgeons and preventive health: a mixed methods study of current practice, beliefs and attitudes influencing health promotion activities amongst public hospital surgeons

BackgroundLittle is known about the participation of surgeons in preventative health activities in the non-admitted hospital care setting. The aim of this study was to identify which preventive health activities surgeons practice and to explore their attitudes towards preventive health.MethodsA mixed methods study was conducted using a sequential explanatory design. Quantitative results were obtained from a self-reported clinician survey (n = 16) and a Generalized Estimating Equation was used to assess the relationship between dependent (preventive health practice) and independent (confidence and knowledge in preventive health practice, years of practice, and attitudinal factors) variables. Using a building approach to integration, results from the quantitative analyses informed design of the interview guide. Surgeons’ beliefs and attitudes were explored using in-depth, semi structured interviews with a purposeful sample of surgeons (n = 14). Responses were collected, independently coded and analysed using a qualitative descriptive approach.ResultsIn accordance with a contiguous narrative approach to integration, the quantitative and qualitative findings are reported separately. The clinician survey found that the surgeons carried out preventive health activities at low levels. Preventive health advice was predominantly verbal in nature, and few surgeons provided written material or referred patients to additional services. The GEE analyses indicated that the following factors best predicted the tendency to undertake preventive health activities: years of clinical practice (p = 0.041), and the perceived work priority placed on preventive health (p = 0.008). Interviews generated four themes that influenced the tendency of surgeons to undertake preventive health activities: perceptions of their role in preventive health, perceived motivation of patients, hospital structure, and facilitating factors. In regards to enabling factors that are likely to increase preventive health practice, surgeons unanimously advocated for referral pathways into specialist behaviour change programs that they could facilitate within their relatively brief consulting time.ConclusionsThe findings suggests that the majority of public hospital surgeons engage in routine preventive health advice at a low level. The high volume of non-admitted surgical consultations undertaken annually, coupled with medium to high self-reported knowledge and confidence in addressing behavioural risk factors, support an increased involvement of surgeons in preventive health practice.

Electronic Consultations in Allergy/Immunology

Allergic condition management more often requires allergist guidance than allergy testing; necessary testing may be unavailable at initial drug allergy consultations. Electronic consultations (e-consults) provide expedited, problem-focused, potentially cost-saving care in other medical specialties, but have not yet been studied in Allergy/Immunology. To describe e-consult use at an academic allergy/immunology practice. E-consult data (August 10, 2016 through July 31, 2018) and in-person consult data (August 1, 2014 through July 31, 2018) were reviewed to determine consult volume, outcomes, indications, and timing. Referral reasons and wait times were compared with chi-square tests. E-consults grew from 1% to 10% of all new consults, with concurrent growth in in-person consults. Of 306 completed e-consults, 41 (13.4%) made diagnostic, therapeutic, or alternative referral recommendations, with 30 (73%) recommendations followed; 183 (59.8%) patients required an in-person Allergy/Immunology consult, and only 5 (<2%) patients saw an allergist without an e-consult recommendation to do so. E-consults were used more often than in-person consults for adverse drug reactions (66% vs 9%; P < .001), especially penicillin allergy (132, 61% of all e-consults) and immunodeficiency (15% vs 2%; P < .001). Allergists completed e-consults in a median of 11 minutes, with a median turnaround time of 22 hours. E-consult implementation was associated with a decreased median in-person consult wait time (1.5 fewer calendar days; P < .05). E-consults were increasingly used, particularly for historical adverse drug reactions and immunodeficiency. Implementation of an e-consult program resulted in decreased in-person wait times despite an increase in overall consult volume, supporting this model's ability to provide expedited, problem-focused care.

Abstract TP270: When Telestroke Programs Work, Bed Size Really Doesn’t Matter

Background: Telestroke rural networks are comprised of micro&gt;small&gt;medium&gt;large sized hospitals without specialized neurology support. Many times the micro hospitals are &lt; 25 beds. In an examination of spoke hospitals in the Arkansas Stroke Assistance through Virtual Emergency Support (AR SAVES) telestroke program, we determined program efficacy correlating bed number. Efficacy was determined by the mean Door-to-ED physician (D2MD) time and door-to-needle (D2N) Alteplase time, and numbers of Alteplase administrations (#Alteplase), mock scenario sessions (#Mocks) and consults (#Consults). Hypothesis: All hospitals would perform equally well with the larger hospitals with slight tendencies to outperform the smaller hospital sites in the #Consults and #Alteplase. Methods: We retrospectively reviewed 2015-2017 spoke hospital data from AR SAVES, the largest statewide telestroke program. The #Mocks and #beds were comparatively analyzed using regression analysis for D2MD, D2N, #Consults and #Alteplase. Spoke sites were categorized by bed numbers; 0-25, 26-50, 51-100, 101-150, 151-200 and &gt; 200. Results: Data from 53 spokes encompassing 2,555 consults over three years indicated that sites &gt; 151 beds were significantly higher in #Alteplase (p &lt; 0.01) and #Consults (p &lt; 0.002). Although the #Mocks were not different among the smaller vs. larger hospitals (p &gt; 0.19), nor was the D2MD time (p=0.82). However, the hospitals &lt; 50 beds had significantly shorter D2N mean time (p &lt; 0.03). The micro (0-25 beds) vs the largest hospitals ( &gt; 200 beds) D2N mean times, were significantly less (76.0±2.5 vs 87.5±4.0 min, p=0.01, respectively). Conclusions: Although the smaller hospitals receive less volume of consults and #Alteplase, with training they perform equally if not better than their larger counterparts.

Abstract TP290: Site-Specific Education Significantly Improves Door-In-Door-Out Times Within a Large Telestroke Network

Introduction: Door-in-door-out (DIDO) is the time between patient arrival at a Stroke Receiving Facility (SRF) and departure for definitive care, with long DIDO times associated with worse outcomes. Our goal was to, in a subset of telestroke (TS) sites, identify barriers to shorter DIDO times and then improve DIDO times. Methods: Our TS network consists of a comprehensive stroke center (hub) and 27 spokes (2 primary stroke centers, 25 SRFs, none thrombectomy-capable). The average spoke-to-hub distance is 190 miles, with only 25% of sites within a 50-mile radius. Based on close proximity to the hub, high consult volumes, and either on-site air or close availability of ACLS ground transport, we chose 5 TS sites as intervention sites to interview and receive targeted education. Baseline data was collected from Jan-Mar 2018 and post-intervention data from Apr-Jun 2018. We conducted site interviews in Mar 2018 to understand current DIDO processes and perceived barriers to shortening times. Customized education was provided based on site demographics, interview data, and State Stroke Task force recommendations. Content focused on the EMS activation process, LVO recognition, and improving ED provider comfort with earlier TS activation. All sites including the 22 control sites received DIDO education through a network newsletter and site coordinator phone calls. We used a t-test to determine if DIDO times differed between the interventional and control sites in the 3 mo pre- vs post-intervention. Results: Pre-intervention mean DIDO time was 185 min for the whole network, 192 (SD 106) for the intervention sites (n=13 transfers), 164 (SD 63) for the control (n=8) (p=NS). Post-intervention, DIDO times were mean 125 min for the network, 90 (SD 28) for intervention sites (n=9 transfers), 148 (SD 75) for controls (n=13) (p&lt;0.02); p&lt;0.005 for intervention site DIDO change between quarters. Intervention sites reported their biggest success was in empowering nursing to active TS sooner and improved communication with EMS activation. Conclusion: Targeted, customized education can significantly reduce DIDO times in a subset of sites of a large TS network. We hope to use this information to facilitate sustainable, reproducible improvement in DIDO times across all our TS sites.

Palliative Care Interdisciplinary Team Effectiveness: Building an Effective Team and Maintaining Team Health (FR454)

•Identify and assess the attributes of a healthy palliative care interdisciplinary team.•Identify and discuss three common threats to individual and team health.•Identify four practices or processes teams can put in place to improve team effectiveness. Has your team ever experienced high turnover, seemingly unmanageable consult volumes, tension among team members, role confusion, or less than effective interdisciplinary team (IDT) performance? How did your team maintain clinical quality? How did your team work together to solve problems or issues that were causing stress? Whether due to growth, the ongoing stresses of providing palliative care to seriously ill patients, or diverse personalities, most teams experience these issues at one time or another. Figuring out how to onboard new team members, identify team issues, and collectively work through challenges as a team is critical, particularly when your team stress is at its peak. This interactive session will provide participants with practical tools and tips for building a high-quality, effective interdisciplinary team in and across hospital, home, clinic, and other settings. An interdisciplinary panel will outline the practices and team processes they have put in place that reinforce team health, ensure role clarity, and improve team communication.