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Reducing time-to-unit among patients referred to an outpatient stroke assessment unit with a novel triage process: a prospective cohort study.

ABSTRACT: BACKGROUND:To evaluate the performance of a novel triage system for Transient Ischemic Attack (TIA) units built upon an existent clinical prediction rule (CPR) to reduce time to unit arrival, relative to the time of symptom onset, for true TIA and minor stroke patients. Differentiating between true and false TIA/minor stroke cases (mimics) is necessary for effective triage as medical intervention for true TIA/minor stroke is time-sensitive and TIA unit spots are a finite resource. METHODS:Prospective cohort study design utilizing patient referral data and TIA unit arrival times from a regional fast-track TIA unit on Vancouver Island, Canada, accepting referrals from emergency departments (ED) and general practice (GP). Historical referral cohort (N?=?2942) from May 2013-Oct 2014 was triaged using the ABCD2 score; prospective referral cohort (N?=?2929) from Nov 2014-Apr 2016 was triaged using the novel system. A retrospective survival curve analysis, censored at 28 days to unit arrival, was used to compare days to unit arrival from event date between cohort patients matched by low (0-3), moderate (4-5) and high (6-7) ABCD2 scores. RESULTS:Survival curve analysis indicated that using the novel triage system, prospectively referred TIA/minor stroke patients with low and moderate ABCD2 scores arrived at the unit 2 and 1 day earlier than matched historical patients, respectively. CONCLUSIONS:The novel triage process is associated with a reduction in time to unit arrival from symptom onset for referred true TIA/minor stroke patients with low and moderate ABCD2 scores.

SUBMITTER: Bibok MB

PROVIDER: S-EPMC6389093 | biostudies-literature | 2018 Feb

REPOSITORIES: biostudies-literature

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Reducing time-to-unit among patients referred to an outpatient stroke assessment unit with a novel triage process: a prospective cohort study.

Bibok Maximilian B MB Votova Kristine K Balshaw Robert F RF Lesperance Mary L ML Croteau Nicole S NS Trivedi Anurag A Morrison Jaclyn J Sedgwick Colin C Penn Andrew M AM

BMC health services research 20180227 1

<h4>Background</h4>To evaluate the performance of a novel triage system for Transient Ischemic Attack (TIA) units built upon an existent clinical prediction rule (CPR) to reduce time to unit arrival, relative to the time of symptom onset, for true TIA and minor stroke patients. Differentiating between true and false TIA/minor stroke cases (mimics) is necessary for effective triage as medical intervention for true TIA/minor stroke is time-sensitive and TIA unit spots are a finite resource.<h4>Met ...[more]

PMID: 29482544

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Project description:BackgroundPatients with cancer are considered at high risk for the novel respiratory illness coronavirus disease 2019 (COVID-19). General measures to keep COVID-19-free cancer divisions have been adopted worldwide. The objective of this study was to evaluate the efficacy of triage to identify COVID-19 among patients with cancer.MethodsFrom March 20 to April 17, 2020, data were collected from patients who were treated or followed at the authors' institution in a prospective clinical trial. The primary endpoint was to estimate the cumulative incidence of COVID-19-positive patients who were identified using a triage process through the aid of medical and patient questionnaires. Based on a diagnostic algorithm, patients with suspect symptoms underwent an infectious disease specialist's evaluation and a COVID-19 swab. Serologic tests were proposed for patients who had symptoms or altered laboratory tests that did not fall into the diagnostic algorithm but were suspicious for COVID-19.ResultsOverall, 562 patients were enrolled. Six patients (1%) were diagnosed with COVID-19, of whom 4 (67%) had the disease detected through telehealth triage, and 2 patients (33%) without suspect symptoms at triage had the disease detected later. Seventy-one patients (13%) had suspect symptoms and/or altered laboratory tests that were not included in the diagnostic algorithm and, of these, 47 patients (73%) underwent testing for severe acute respiratory syndrome coronavirus 2 antibody: 6 (13%) were positive for IgG (n = 5) or for both IgM and IgG (n = 1), and antibody tests were negative in the remaining 41 patients.ConclusionsThe triage process had a positive effect on the detection of COVID-19 in patients with cancer. Telehealth triage was helpful in detecting suspect patients and to keep a COVID-19-free cancer center. The overall incidence of COVID-19 diagnosis (1%) and antibody positivity (13%) in patients with suspect symptoms was similar to that observed in the general population.

Project description:Better outcomes are obtained with stroke thrombolysis the more rapidly it is given, both in terms of the patient's level of functional ability and also mortality. Current UK performance targets (outside London) aim for a time of 45 minutes or less. Thrombolysis pathways involve multidisciplinary working across departmental boundaries as well as senior level decision making. Our system used telemedicine out of hours adding additional complexity to the pathway. The initial planning stages started by auditing current practice and mapping the existing pathway. The figures for door to needle times were held on a database on the stroke unit and collected in detail for the purposes of national reporting. The pathway was mapped by combining personal experience of working within the stroke service with the experiences of the general medical registrars who worked the system out of hours. The initial action was to present this information throughout the hospital at departmental meetings. Opinions were canvassed at these meetings on where the biggest barriers were within the pathway and how we could address them. An awareness campaign was held by advertising over the intranet. An intervention comprising the following elements was introduced over the period of a year: introduction of an ambulance pre-alert, revision of the existing pathway, and education to all those involved in thrombolysis. The cases where particularly long delays were noted were audited in more depth to identify barriers to flow through the system. This was reported in ward meetings for staff to contribute experience and to offer solutions. We went to commissioning group meetings to gain the support of the local ambulance service, and talked to A&E seniors about the project and the ways in which they could help. Median times were calculated from a stroke database. There was a fall in median door to needle time of 65.5 to 49 minutes over a period of 18 months. A complex intervention to improve door to needle time can and did produce good results with a reduction in times to within the London performance standards of care. The efficacy could be improved with an increased staffing level and provision of a formal setting within which to discuss changes and to keep up the momentum of change.

Project description:ImportanceTransferring patients with large-vessel occlusion (LVO) or intracranial hemorrhage (ICH) to hospitals not providing interventional treatment options is an unresolved medical problem.ObjectiveTo determine how optimized prehospital management (OPM) based on use of the Los Angeles Motor Scale (LAMS) compares with management in a Mobile Stroke Unit (MSU) in accurately triaging patients to the appropriate hospital with (comprehensive stroke center [CSC]) or without (primary stroke center [PSC]) interventional treatment.Design, setting, and participantsIn this randomized multicenter trial with 3-month follow-up, patients were assigned week-wise to one of the pathways between June 15, 2015, and November 15, 2017, in 2 regions of Saarland, Germany; 708 of 824 suspected stroke patients did not meet inclusion criteria, resulting in a study population of 116 adult patients.InterventionsPatients received either OPM based on a standard operating procedure that included the use of the LAMS (cut point ≥4) or management in an MSU (an ambulance with vascular imaging, point-of-care laboratory, and telecommunication capabilities).Main outcomes and measuresThe primary end point was the proportion of patients accurately triaged to either CSCs (LVO, ICH) or PSCs (others).ResultsA predefined interim analysis was performed after 116 patients of the planned 232 patients had been enrolled. Of these, 53 were included in the OPM group (67.9% women; mean [SD] age, 74 [11] years) and 63 in the MSU group (57.1% women; mean [SD] age, 75 [11] years). The primary end point, an accurate triage decision, was reached for 37 of 53 patients (69.8%) in the OPM group and for 63 of 63 patients (100%) in the MSU group (difference, 30.2%; 95% CI, 17.8%-42.5%; P < .001). Whereas 7 of 17 OPM patients (41.2%) with LVO or ICH required secondary transfers from a PSC to a CSC, none of the 11 MSU patients (0%) required such transfers (difference, 41.2%; 95% CI, 17.8%-64.6%; P = .02). The LAMS at a cut point of 4 or higher led to an accurate diagnosis of LVO or ICH for 13 of 17 patients (76.5%; 6 triaged to a CSC) and of LVO selectively for 7 of 9 patients (77.8%; 2 triaged to a CSC). Stroke management metrics were better in the MSU group, although patient outcomes were not significantly different.Conclusions and relevanceWhereas prehospital management optimized by LAMS allows accurate triage decisions for approximately 70% of patients, MSU-based management enables accurate triage decisions for 100%. Depending on the specific health care environment considered, both approaches are potentially valuable in triaging stroke patients.Trial registrationClinicalTrials.gov identifier: NCT02465346.

Project description:BackgroundNon-attendance to scheduled hospital outpatient appointments may compromise healthcare resource planning, which ultimately reduces the quality of healthcare provision by delaying assessments and increasing waiting lists. We developed a model for predicting non-attendance and assessed the effectiveness of an intervention for reducing non-attendance based on the model.MethodsThe study was conducted in three stages: (1) model development, (2) prospective validation of the model with new data, and (3) a clinical assessment with a pilot study that included the model as a stratification tool to select the patients in the intervention. Candidate models were built using retrospective data from appointments scheduled between January 1, 2015, and November 30, 2018, in the dermatology and pneumology outpatient services of the Hospital Municipal de Badalona (Spain). The predictive capacity of the selected model was then validated prospectively with appointments scheduled between January 7 and February 8, 2019. The effectiveness of selective phone call reminders to patients at high risk of non-attendance according to the model was assessed on all consecutive patients with at least one appointment scheduled between February 25 and April 19, 2019. We finally conducted a pilot study in which all patients identified by the model as high risk of non-attendance were randomly assigned to either a control (no intervention) or intervention group, the last receiving phone call reminders one week before the appointment.ResultsDecision trees were selected for model development. Models were trained and selected using 33,329 appointments in the dermatology service and 21,050 in the pneumology service. Specificity, sensitivity, and accuracy for the prediction of non-attendance were 79.90%, 67.09%, and 73.49% for dermatology, and 71.38%, 57.84%, and 64.61% for pneumology outpatient services. The prospective validation showed a specificity of 78.34% (95%CI 71.07, 84.51) and balanced accuracy of 70.45% for dermatology; and 69.83% (95%CI 60.61, 78.00) for pneumology, respectively. The effectiveness of the intervention was assessed on 1,311 individuals identified as high risk of non-attendance according to the selected model. Overall, the intervention resulted in a significant reduction in the non-attendance rate to both the dermatology and pneumology services, with a decrease of 50.61% (p<0.001) and 39.33% (p=0.048), respectively.ConclusionsThe risk of non-attendance can be adequately estimated using patient information stored in medical records. The patient stratification according to the non-attendance risk allows prioritizing interventions, such as phone call reminders, to effectively reduce non-attendance rates.

Project description:IntroductionThe efficacy of both intravenous treatment (IVT) and endovascular treatment (EVT) for patients with acute ischaemic stroke strongly declines over time. Only a subset of patients with ischaemic stroke caused by an intracranial large vessel occlusion (LVO) in the anterior circulation can benefit from EVT. Several prehospital stroke scales were developed to identify patients that are likely to have an LVO, which could allow for direct transportation of EVT eligible patients to an endovascular-capable centre without delaying IVT for the other patients. We aim to prospectively validate these prehospital stroke scales simultaneously to assess their accuracy in predicting LVO in the prehospital setting.Methods and analysisPrehospital triage of patients with suspected stroke symptoms (PRESTO) is a prospective multicentre observational cohort study in the southwest of the Netherlands including adult patients with suspected stroke in the ambulance. The paramedic will assess a combination of items from five prehospital stroke scales, without changing the normal workflow. Primary outcome is the clinical diagnosis of an acute ischaemic stroke with an intracranial LVO in the anterior circulation. Additional hospital data concerning the diagnosis and provided treatment will be collected by chart review. Logistic regression analysis will be performed, and performance of the prehospital stroke scales will be expressed as sensitivity, specificity and area under the receiver operator curve.Ethics and disseminationThe Institutional Review Board of the Erasmus MC University Medical Centre has reviewed the study protocol and confirmed that the Dutch Medical Research Involving Human Subjects Act (WMO) is not applicable. The findings of this study will be disseminated widely through peer-reviewed publications and conference presentations. The best performing scale, or the simplest scale in case of clinical equipoise, will be integrated in a decision model with other clinical characteristics and real-life driving times to improve prehospital triage of suspected stroke patients.Trial registration numberNTR7595.

Project description:BACKGROUND:Although the surgical pause or time-out is a required part of most hospitals' standard operating procedures, little is known about the quality of execution of the time-out in routine clinical practice. An interactive electronic time-out was implemented to increase surgical team compliance with the time-out procedure and to improve communication among team members in the operating room. We sought to identify nonroutine events that occur during the time-out procedure in the operating room, including distractions and interruptions, deviations from protocol, and the problem-solving strategies used by operating room team members to mitigate them. METHODS:Direct observations of surgical time-outs were performed on 166 nonemergent surgeries in 2016. For each time-out, the observers recorded compliance with each step, any nonroutine events that may have occurred, and whether any operating room team members were distracted. RESULTS:The time-out procedure was performed before the first incision in 100% of cases. An announcement was made to indicate the start of the time-out procedure in 163 of 166 observed surgeries. Most observed time-outs were completed in <1 minute. Most time-outs were completed without interruption (92.8%). The most common reason for an interruption was to verify patient information. Ten time-out procedures were stopped due to a safety concern. At least 1 member of the operating room team was actively distracted in 10.2% of the time-out procedures observed. CONCLUSIONS:Compliance with preincision time-outs is high at our institution, and nonroutine events are a rare occurrence. It is common for ?1 member of the operating room team to be actively distracted during time-out procedures, even though most time-outs are completed in under 1 minute. Despite distractions, there were no wrong-site or wrong-person surgeries reported at our hospital during the study period. We conclude that the simple act of performing a preprocedure checklist may be completed quickly, but that distractions are common.

Dataset Information

Reducing time-to-unit among patients referred to an outpatient stroke assessment unit with a novel triage process: a prospective cohort study.

Publications

Reducing time-to-unit among patients referred to an outpatient stroke assessment unit with a novel triage process: a prospective cohort study.

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