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INTRODUCTION: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a temporizing hemorrhage control intervention, but its inevitable effect on time to operating room (OR) has not been assessed. The aim of our study is to assess the impact of undergoing REBOA before surgery (RBS) on time to definitive hemorrhage control surgery. METHODS: In this retrospective analysis of 2017-2021 ACS-TQIP database, all adult (≥18 years) patients who underwent emergency hemorrhage control laparotomy (≤4 hours of admission) and received early blood products (≤4 hours) were included, and patients with severe head injury (Head-abbreviated injury score > 2) were excluded. Patients were stratified into those who did (RBS) vs those who did not undergo REBOA before surgery (No-RBS). Primary outcome was time to laparotomy. Secondary outcomes were complications and mortality. Multivariable linear and binary logistic regression analyses were performed to identify the independent associations between RBS and outcomes. RESULTS: A total of 32,683 patients who underwent emergency laparotomy were identified (RBS: 342; No-RBS: 32,341). The mean age was 39 (16) years, 78% were male, mean SBP was 107 (34) mmHg, and the median injury severity score was 21 [14-29]. The median time to emergency hemorrhage control surgery was 50 [32-85] minutes. Overall complication rate was 16% and mortality was 19%. On univariate analysis, RBS group had longer time to surgery (RBS 56 [41-89] vs No-RBS 50 [32-85] minutes, P < 0.001). On multivariable analysis, RBS was independently associated with a longer time to hemorrhage control surgery (ß + 14.5 [95%CI 7.8-21.3], P < 0.001), higher odds of complications (aOR = 1.72, 95%CI = 1.27-2.34, P < 0.001), and mortality (aOR = 3.42, 95%CI = 2.57-4.55, P < 0.001). CONCLUSION: REBOA is independently associated with longer time to OR for hemorrhaging trauma patients with an average delay of 15 minutes. Further research evaluating center-specific REBOA volume and utilization practices, and other pertinent system factors, may help improve both time to REBOA as well as time to definitive hemorrhage control across US trauma centers. LEVEL OF EVIDENCE: III. STUDY TYPE: Epidemiologic.
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Oclusión con Balón , Hemorragia , Humanos , Masculino , Estudios Retrospectivos , Femenino , Adulto , Oclusión con Balón/métodos , Oclusión con Balón/normas , Oclusión con Balón/estadística & datos numéricos , Persona de Mediana Edad , Hemorragia/etiología , Hemorragia/epidemiología , Resucitación/métodos , Resucitación/estadística & datos numéricos , Resucitación/normas , Tiempo de Tratamiento/estadística & datos numéricos , Tiempo de Tratamiento/normas , Factores de Tiempo , Modelos Logísticos , Puntaje de Gravedad del Traumatismo , Aorta/cirugía , Laparotomía/métodos , Laparotomía/estadística & datos numéricos , Laparotomía/efectos adversosRESUMEN
BACKGROUND: The English National Health Service has multiple waiting time standards relating to cancer diagnosis and treatment. Targets can have unintended effects, such as prioritisation based on targets instead of clinical need. In this case, a `threshold effect' will appear as a spike in hospitals just meeting the target. METHODS: We conducted a retrospective study of publicly available cancer waiting time data, including a 2-week wait for a specialist appointment, a 31-day decision to first treatment and a 62-day referral to treatment standard that attracted a financial penalty. We examined the performance of hospital trusts against these targets by financial year to look for threshold effects, using Cattaneo et al. manipulation density test. RESULTS: Trust performance against cancer waiting targets declined over time, and this trend accelerated since the start of the Covid-19 pandemic. Statistical evidence of a threshold effect for the 2-week and 31-day standard was only present in a few years. However, there was strong statistical evidence of a threshold effect for the 62-day standard across all financial years (p < 0.01). CONCLUSION: The data suggests that the effect of threshold targets alters hospital behaviour at target levels but does not do so equally for all standards. Evidence of threshold effects for the 62-day standard was particularly strong, possibly due to some combination of a smaller volume of eligible patients, a larger penalty, multiple waypoints where hospitals can intervene, baseline performance against the target and where the target is set (i.e. how much headroom is available). RCTs of the use of threshold targets and of different designs for such targets in the future would be extremely informative.
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COVID-19 , Neoplasias , Medicina Estatal , Listas de Espera , Humanos , Estudios Retrospectivos , Neoplasias/terapia , COVID-19/epidemiología , Inglaterra , SARS-CoV-2 , Pandemias , Tiempo de Tratamiento/normas , Derivación y Consulta/normasRESUMEN
BACKGROUND: Door-to-balloon time (DTBT) for ST-elevation myocardial infarction (STEMI) is a performance metric by which primary percutaneous coronary intervention (PPCI) services are assessed. METHODS: Consecutive patients presenting with STEMI undergoing PPCI between January 2007 to December 2019 from the Singapore Myocardial Infarction Registry were included. Patients were stratified based on DTBT (≤60 min, 61-90 min, 91-180 min) and Killip status (I-III vs. IV). Outcomes assessed included all-cause mortality and major adverse cardiovascular events (MACE) at 30-days and 1-year. RESULTS: In total, 13,823 patients were included, with 82.59% achieving DTBT ≤90 min and 49.77% achieving DTBT ≤60 min. For Killip I-III (n = 11,591,83.85%), the median DTBT was 60[46-78]min. The 30-day all-cause mortality for DTBT of ≤60 min, 61-90 min and 91-180 min was 1.08%, 2.17% and 4.33% respectively (p < 0.001). On multivariate analysis, however, there was no significant difference for 30-day and 1-year outcomes across all DTBT (p > 0.05). For Killip IV, the median DTBT was 68[51-91]min. The 30-day all-cause mortality for DTBT of ≤60 min, 61-90 min and 91-180 min was 11.74%, 20.48% and 35.06% respectively (p < 0.001). On multivariate analysis for 30-day and 1-year outcomes, DTBT 91-180 min was an independent predictor of worse outcomes (p < 0.05), but there was no significant difference between DTBT of ≤60 min and 61-90 min (p > 0.05). CONCLUSION: In Killip I-III patients, DTBT had no significant impact on outcomes upon adjustment for confounders. Conversely, for Killip IV patients, a DTBT of >90 min was associated with significantly higher adverse outcomes, with no differences between a DTBT of ≤60 min vs. 61-90 min. Outcomes in STEMI involve a complex interplay of factors and recommendations of a lowered DTBT of ≤60 min will require further evaluation.
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Intervención Coronaria Percutánea , Sistema de Registros , Infarto del Miocardio con Elevación del ST , Tiempo de Tratamiento , Humanos , Masculino , Femenino , Infarto del Miocardio con Elevación del ST/cirugía , Infarto del Miocardio con Elevación del ST/terapia , Infarto del Miocardio con Elevación del ST/mortalidad , Persona de Mediana Edad , Tiempo de Tratamiento/normas , Anciano , Intervención Coronaria Percutánea/métodos , Singapur/epidemiología , Factores de Tiempo , Resultado del Tratamiento , Estudios RetrospectivosRESUMEN
Objectives: This study aimed to estimate the door-to-balloon (DTB) time and determine the organisational-level factors that influence delayed DTB times among patients with ST-elevation myocardial infarction in Oman. Methods: A cross-sectional retrospective study was conducted on all patients who presented to the emergency department at Sultan Qaboos University Hospital and Royal Hospital, Muscat, Oman, and underwent primary percutaneous coronary interventions during 2018-2019. Results: The sample included 426 patients and the median DTB time was 142 minutes. The result of the bivariate logistic regression showed that patients who presented to the emergency department with atypical symptoms were 3 times more likely to have a delayed DTB time, when compared to patients who presented with typical symptoms (odds ratio [OR] = 3.003, 95% confidence interval [CI]: 1.409-6.400; P = 0.004). In addition, patients who presented during off-hours were 2 times more likely to have a delayed DTB time, when compared to patients who presented during regular working hours (OR = 2.291, 95% CI: 1.284-4.087; P = 0.005). Conclusion: To meet the DTB time recommendation, it is important to ensure adequate staffing during both regular and irregular working hours. Results from this study can be used as a baseline for future studies and inform strategies for improving the quality of care.
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Servicio de Urgencia en Hospital , Infarto del Miocardio con Elevación del ST , Tiempo de Tratamiento , Humanos , Femenino , Estudios Transversales , Masculino , Estudios Retrospectivos , Infarto del Miocardio con Elevación del ST/terapia , Omán , Persona de Mediana Edad , Tiempo de Tratamiento/estadística & datos numéricos , Tiempo de Tratamiento/normas , Anciano , Servicio de Urgencia en Hospital/estadística & datos numéricos , Servicio de Urgencia en Hospital/organización & administración , Factores de Tiempo , Intervención Coronaria Percutánea/estadística & datos numéricos , Intervención Coronaria Percutánea/métodos , Adulto , Modelos LogísticosRESUMEN
INTRODUCTION: Pain, more frequently due to musculoskeletal injuries, is a prevalent concern in emergency departments (EDs). Timely analgesic administration is paramount in the acute setting of ED. Despite its importance, many EDs face challenges in pain management and present opportunities for improvement. This initiative aimed to expedite the administration of the first analgesic in patients with musculoskeletal pain in the ED. LOCAL PROBLEM: Observations within our ED revealed that patients with musculoskeletal injuries triaged to yellow or green areas experienced prolonged waiting times, leading to delayed analgesic administration, thereby adversely affecting clinical care and patient satisfaction. SPECIFIC AIM: The aim of our quality improvement (QI) project was to reduce the time to administration of first analgesia by 30% from baseline, in patients with musculoskeletal injuries presenting to our academic ED, in a period of 8 weeks after the baseline phase. METHODS: A multidisciplinary QI team systematically applied Point-of-Care Quality Improvement and Plan-Do-Study-Act (PDSA) cycle methodologies. Process mapping and fishbone analyses identified the challenges in analgesia administration. Targeted interventions were iteratively refined through PDSA cycles. INTERVENTIONS: Interventions such as pain score documentation at triage, fast-tracking of patients with moderate-to-severe pain, resident awareness sessions, a pain management protocol and prescription audits were executed during the PDSA cycles. Successful elements were reinforced and adjustments were made to address the identified challenges. RESULTS: The median door-to-analgesia timing during the baseline phase was 55.5 min (IQR, 25.75-108 min). During the postintervention phase, the median was significantly reduced to 15 min (IQR, 5-37 min), exceeding the anticipated outcomes and indicating a substantial 73% reduction (p value <0.001) from baseline. CONCLUSION: Implementing simple change ideas resulted in a substantial improvement in door-to-analgesia timing within the ED. These findings significantly contribute to ongoing discussions on the optimisation of pain management in emergency care.
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Servicio de Urgencia en Hospital , Manejo del Dolor , Mejoramiento de la Calidad , Humanos , Servicio de Urgencia en Hospital/organización & administración , Servicio de Urgencia en Hospital/estadística & datos numéricos , Manejo del Dolor/métodos , Manejo del Dolor/normas , Manejo del Dolor/estadística & datos numéricos , India , Femenino , Masculino , Tiempo de Tratamiento/estadística & datos numéricos , Tiempo de Tratamiento/normas , Adulto , Analgesia/métodos , Analgesia/normas , Analgesia/estadística & datos numéricos , Analgésicos/uso terapéutico , Analgésicos/administración & dosificación , Persona de Mediana Edad , Dolor Musculoesquelético/terapia , Dimensión del Dolor/métodos , Dimensión del Dolor/estadística & datos numéricos , Factores de TiempoRESUMEN
BACKGROUND: Early administration of antibiotics in the presence of open fractures is critical in reducing infections and later complications. Current guidelines recommend administering antibiotics within 60 min of patient arrival to the emergency department, yet trauma centers often struggle to meet this metric. OBJECTIVES: This study aims to evaluate the impact of a nurse-initiated evidence-based treatment protocol on the timeliness of antibiotic administration in pediatric patients with open fractures. METHODS: A retrospective pre-post study of patients who met the National Trauma Data Standard registry inclusion criteria for open fractures of long bones, amputations, or lawn mower injuries was performed at a Midwestern United States Level II pediatric trauma center. The time of patient arrival and time of antibiotic administration from preimplementation (2015-2020) to postimplementation (2021-2022) of the protocol were compared. Patients transferred in who received antibiotics at an outside facility were excluded. RESULTS: A total of N = 73 participants met the study inclusion criteria, of which n = 41 were in the preimplementation group and n = 32 were in the postimplementation group. Patients receiving antibiotics within 60 min of arrival increased from n = 24/41 (58.5%) preimplementation to n = 26/32 (84.4%) postimplementation (p< .05). CONCLUSIONS: Our study demonstrates that initiating evidence-based treatment orders from triage helped decrease the time from arrival to time of antibiotic administration in patients with open fractures. We sustained improvement for 24 months after the implementation of our intervention.
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Antibacterianos , Fracturas Abiertas , Centros Traumatológicos , Humanos , Fracturas Abiertas/enfermería , Fracturas Abiertas/tratamiento farmacológico , Estudios Retrospectivos , Antibacterianos/administración & dosificación , Masculino , Niño , Femenino , Preescolar , Protocolos Clínicos , Adolescente , Tiempo de Tratamiento/normas , Factores de Tiempo , Medio Oeste de Estados UnidosRESUMEN
BACKGROUND: The mortality rate of pediatric patients who require continuous renal replacement therapy is approximately 42%, and outcomes vary considerably depending on underlying disease, illness severity, and time of dialysis initiation. Delay in the initiation of such therapy may increase mortality risk, prolong intensive care unit stay, and worsen clinical outcomes. LOCAL PROBLEM: In the pediatric intensive care unit of an urban level I trauma children's hospital, continuous renal replacement therapy initiation times and factors associated with delays in therapy were unknown. METHODS: This quality improvement process involved a retrospective review of data on patients who received continuous dialysis in the pediatric intensive care unit from January 1, 2017, to December 31, 2021. The objectives were to examine the characteristics of the children requiring continuous renal replacement therapy, therapy initiation times, and factors associated with initiation delays that might affect unit length of stay and mortality. RESULTS: During the study period, 175 patients received continuous renal replacement therapy, with an average initiation time of 11.9 hours. Statistically significant associations were found between the degree of fluid overload and mortality (P < .001) and between the presence of acute kidney injury and prolonged length of stay (P = .04). No significant association was found between therapy initiation time and unit length of stay or mortality, although the average initiation time of survivors was 5.9 hours shorter than that of nonsurvivors. CONCLUSION: Future studies are needed to assess real time delays and to evaluate if the implementation of a standardized initiation process decreases initiation time.
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Lesión Renal Aguda , Terapia de Reemplazo Renal Continuo , Enfermedad Crítica , Unidades de Cuidado Intensivo Pediátrico , Humanos , Masculino , Femenino , Estudios Retrospectivos , Niño , Lesión Renal Aguda/terapia , Lesión Renal Aguda/mortalidad , Preescolar , Lactante , Adolescente , Tiempo de Internación/estadística & datos numéricos , Factores de Tiempo , Terapia de Reemplazo Renal , Recién Nacido , Mejoramiento de la Calidad , Tiempo de Tratamiento/normasRESUMEN
BACKGROUND: Bacteraemia is a critical condition that generally leads to substantial morbidity and mortality. It is unclear whether delayed antimicrobial therapy (and/or source control) has a prognostic or defervescence effect on patients with source-control-required (ScR) or unrequired (ScU) bacteraemia. METHODS: The multicenter cohort included treatment-naïve adults with bacteraemia in the emergency department. Clinical information was retrospectively obtained and etiologic pathogens were prospectively restored to accurately determine the time-to-appropriate antibiotic (TtAa). The association between TtAa or time-to-source control (TtSc, for ScR bacteraemia) and 30-day crude mortality or delayed defervescence were respectively studied by adjusting independent determinants of mortality or delayed defervescence, recognised by a logistic regression model. RESULTS: Of the total 5477 patients, each hour of TtAa delay was associated with an average increase of 0.2% (adjusted odds ratio [AOR], 1.002; P < 0.001) and 0.3% (AOR 1.003; P < 0.001) in mortality rates for patients having ScU (3953 patients) and ScR (1524) bacteraemia, respectively. Notably, these AORs were augmented to 0.4% and 0.5% for critically ill individuals. For patients experiencing ScR bacteraemia, each hour of TtSc delay was significantly associated with an average increase of 0.31% and 0.33% in mortality rates for overall and critically ill individuals, respectively. For febrile patients, each additional hour of TtAa was significantly associated with an average 0.2% and 0.3% increase in the proportion of delayed defervescence for ScU (3085 patients) and ScR (1266) bacteraemia, respectively, and 0.5% and 0.9% for critically ill individuals. For 1266 febrile patients with ScR bacteraemia, each hour of TtSc delay respectively was significantly associated with an average increase of 0.3% and 0.4% in mortality rates for the overall population and those with critical illness. CONCLUSIONS: Regardless of the need for source control in cases of bacteraemia, there seems to be a significant association between the prompt administration of appropriate antimicrobials and both a favourable prognosis and rapid defervescence, particularly among critically ill patients. For ScR bacteraemia, delayed source control has been identified as a determinant of unfavourable prognosis and delayed defervescence. Moreover, this association with patient survival and the speed of defervescence appears to be augmented among critically ill patients.
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Bacteriemia , Servicio de Urgencia en Hospital , Humanos , Bacteriemia/tratamiento farmacológico , Bacteriemia/mortalidad , Masculino , Femenino , Persona de Mediana Edad , Servicio de Urgencia en Hospital/organización & administración , Servicio de Urgencia en Hospital/estadística & datos numéricos , Anciano , Estudios Retrospectivos , Adulto , Antibacterianos/uso terapéutico , Factores de Tiempo , Estudios de Cohortes , Antiinfecciosos/uso terapéutico , Tiempo de Tratamiento/estadística & datos numéricos , Tiempo de Tratamiento/normasRESUMEN
OBJECTIVE: A systematic review was conducted to evaluate the time delays in the management of diabetic foot and explore influencing factors of these delays and potential outcomes. METHODS: The researchers searched several electronic databases (Pubmed, Web of Science, Cochrane Library, EMbase, CNKI, WanFang, CBM and VIP) for English and Chinese studies that examined time delays in the management pathway of diabetic foot. Two authors independently screened and extracted data, and assessed the quality of the included studies using the Newcastle-Ottawa Scale and the Agency for Health Research and Quality checklist. Due to heterogeneity among the studies, descriptive analysis was performed. RESULTS: The review included 28 articles, comprising 20 cohort studies and 8 cross-sectional studies, that met the inclusion criteria. Among these, 14 were deemed of high quality. The median times from symptom onset to primary health care or specialist care varied from 3 to 46.69 days. The median delay in referral by primary care specialists ranged from 7 to 31 days, and subsequent median times to definitive treatment ranged from 6.2 to 56 days. Multiple complex factors were found to contribute to these delays, including patient demographics (older age, lower education level and income level) and poor patient health-seeking behaviors (inaccurate self-treatment, incorrect recognition and interpretation of symptoms), inaccurate assessment or initial treatment by health primary professionals, complex referral pathways and clinical characteristics of diabetic foot (number of foot ulcers, Wagner grade scale, and hemoglobin A1c index). Negative outcomes associated with these delays included increased risk of major amputation and mortality, decreased wound healing rate, prolonged hospital stay, and increased hospital costs. CONCLUSIONS: Time delays in the diabetic foot management pathway were both common and serious, contributing to negative health outcomes for patients with diabetic foot. Many complex factors related to patient's poor patient health-seeking behaviors, health system, and clinical characteristics of diabetic foot are responsible for these delays. Therefore, it is necessary to develop new strategies for standard referral practices and strengthen patient awareness of seeking care.
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Pie Diabético , Humanos , Pie Diabético/terapia , Factores de Tiempo , Tiempo de Tratamiento/estadística & datos numéricos , Tiempo de Tratamiento/normasRESUMEN
INTRODUCTION: Survival following emergency department thoracotomy (EDT) for patients in extremis is poor. Whether intervention in the operating room instead of EDT in select patients could lead to improved outcomes is unknown. We hypothesized that patients who underwent intervention in the operating room would have improved outcomes compared to those who underwent EDT. METHODS: We conducted a retrospective review of the Trauma Quality Improvement Program database from 2017 to 2021. All adult patients who underwent EDT, operating room thoracotomy (ORT), or sternotomy as the first form of surgical intervention within 1 h of arrival were included. Of patients without prehospital cardiac arrest, propensity score matching was utilized to create three comparable groups. The primary outcome was survival. Secondary outcomes included time to procedure. RESULTS: There were 1865 EDT patients, 835 ORT patients, and 456 sternotomy patients who met the inclusion criteria. There were 349 EDT, 344 ORT, and 408 sternotomy patients in the matched analysis. On Cox multivariate regression, there was an increased risk of mortality with EDT versus sternotomy (HR 4.64, P < 0.0001), EDT versus ORT (HR 1.65, P < 0.0001), and ORT versus sternotomy (HR 2.81, P < 0.0001). Time to procedure was shorter with EDT versus sternotomy (22 min versus 34 min, P < 0.0001) and versus ORT (22 min versus 37 min, P < 0.0001). CONCLUSIONS: There was an association between sternotomy and ORT versus EDT and improved mortality. In select patients, operative approaches rather than the traditional EDT could be considered.
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Bases de Datos Factuales , Servicio de Urgencia en Hospital , Puntaje de Propensión , Mejoramiento de la Calidad , Esternotomía , Toracotomía , Humanos , Toracotomía/mortalidad , Toracotomía/estadística & datos numéricos , Femenino , Masculino , Estudios Retrospectivos , Persona de Mediana Edad , Servicio de Urgencia en Hospital/estadística & datos numéricos , Adulto , Esternotomía/estadística & datos numéricos , Bases de Datos Factuales/estadística & datos numéricos , Anciano , Tiempo de Tratamiento/estadística & datos numéricos , Tiempo de Tratamiento/normas , Quirófanos/estadística & datos numéricos , Quirófanos/organización & administración , Quirófanos/normasRESUMEN
BACKGROUND/AIM: The purpose of this study was to determine socioeconomic and demographic factors which may contribute to inequities in time to treat thyroid cancer. PATIENTS AND METHODS: We used data from the National Cancer Database, 2004-2019, to conduct an analysis of thyroid cancer patients. All (434,083) patients with thyroid cancer, including papillary (395,598), follicular (23,494), medullary (7,638), and anaplastic (7,353) types were included. We compared the wait time from diagnosis to first treatment, surgery, radiotherapy, and chemotherapy for patients based on age, race, sex, location, and socioeconomic status (SES). RESULTS: A total of 434,083 patients with thyroid cancer were included. Hispanic patients had significantly longer wait times to all treatments compared to non-Hispanic patients (first treatment 33.44 vs. 20.45 days, surgery 40.06 vs. 26.49 days, radiotherapy 114.68 vs. 96.42 days, chemotherapy 92.70 vs. 58.71 days). Uninsured patients, patients at academic facilities, and patients in metropolitan areas also had the longest wait times to treatment. CONCLUSION: This study identified multiple disparities related to SES and demographics that correspond to delays in time to treatment. It is crucial that this topic is investigated further to help mitigate these incongruities in thyroid cancer care in the future.
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Disparidades en Atención de Salud , Neoplasias de la Tiroides , Retraso del Tratamiento , Humanos , Bases de Datos Factuales/estadística & datos numéricos , Hispánicos o Latinos/estadística & datos numéricos , Oncología por Radiación , Neoplasias de la Tiroides/diagnóstico , Neoplasias de la Tiroides/epidemiología , Neoplasias de la Tiroides/etnología , Neoplasias de la Tiroides/terapia , Disparidades en Atención de Salud/etnología , Disparidades en Atención de Salud/normas , Disparidades en Atención de Salud/estadística & datos numéricos , Tiempo de Tratamiento/normas , Tiempo de Tratamiento/estadística & datos numéricos , Retraso del Tratamiento/normas , Retraso del Tratamiento/estadística & datos numéricosRESUMEN
BACKGROUND: Cancer patient pathways (CPPs) were implemented in Norway to reduce unnecessary waiting times, regional variations, and to increase the predictability of cancer care for the patients. This study aimed to determine if 70% of cancer patients started treatment within the recommended time frames, and to identify potential delays. METHODS: Patients registered with a colorectal, lung, breast, or prostate cancer diagnosis at the Cancer Registry of Norway in 2015-2016 were linked with the Norwegian Patient Registry and Statistics Norway. Adjusting for sociodemographic variables, multivariable quantile (median) regressions were used to examine the association between place of residence and median time to start of examination, treatment decision, and start of treatment. RESULTS: The study included 20 668 patients. The proportions of patients who went through the CPP within the recommended time frames were highest among colon (84%) and breast (76%) cancer patients who underwent surgery and lung cancer patients who started systemic anticancer treatment (76%), and lowest for prostate cancer patients who underwent surgery (43%). The time from treatment decision to start of treatment was the main source of delay for all cancers. Travelling outside the resident health trust prolonged waiting time and was associated with a reduced odds of receiving surgery and radiotherapy for lung and rectal cancer patients, respectively. CONCLUSIONS: Achievement of national recommendations of the CCP times differed by cancer type and treatment. Identified bottlenecks in the pathway should be targeted to decrease waiting times. Further, CPP guidelines should be re-examined to determine their ongoing relevance.
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Vías Clínicas/estadística & datos numéricos , Neoplasias/terapia , Aceptación de la Atención de Salud/estadística & datos numéricos , Cooperación del Paciente/estadística & datos numéricos , Tiempo de Tratamiento/estadística & datos numéricos , Adulto , Anciano , Anciano de 80 o más Años , Vías Clínicas/normas , Femenino , Geografía , Humanos , Almacenamiento y Recuperación de la Información , Masculino , Persona de Mediana Edad , Noruega , Sistema de Registros , Factores de Tiempo , Tiempo de Tratamiento/normas , Listas de EsperaRESUMEN
BACKGROUND: In 2010, HIV treatment as prevention (TasP), encompassing widespread HIV testing and immediate initiation of free antiretroviral treatment (ART), was piloted under the Seek and Treat for Optimal Prevention of HIV/AIDS initiative (STOP) in British Columbia, Canada. We compared the time from HIV diagnosis to treatment initiation, and from treatment initiation to first virologic suppression, before (2005-2009) and after (2010-2016) the implementation of STOP. METHODS: In this population-based cohort study, we used longitudinal data of all people living with an HIV diagnosis in BC from 1996 to 2017. We included those aged 18 years or older who had never received ART and had received an HIV diagnosis in the 2005-2016 period. We defined the virologic suppression date as the first date of at least 2 consecutive test results within 4 months with a viral load of less than 200 copies/mL. Negative binomial regression models assessed the effect of STOP on the time to ART initiation and suppression, adjusting for confounders. All p values were 2-sided, and we set the significance level at 0.05. RESULTS: Participants who received an HIV diagnosis before STOP (n = 1601) were statistically different from those with a diagnosis after STOP (n = 1700); 81% versus 84% were men (p = 0.0187), 30% versus 15% had ever injected drugs (p < 0.0001), and 27% versus 49% had 350 CD4 cells/µL or more at diagnosis (p < 0.0001). The STOP initiative was associated with a 64% shorter time from diagnosis to treatment (adjusted mean ratio 0.36, 95% confidence interval [CI] 0.34-0.39) and a 21% shorter time from treatment to suppression (adjusted mean ratio 0.79, 95% CI 0.73-0.85). INTERPRETATION: In a population with universal health coverage, a TasP intervention was associated with shorter times from HIV diagnosis to treatment initiation, and from treatment initiation to viral suppression. Our results show accelerating progress toward the United Nations' 90-90-90 target of people with HIV who have a diagnosis, those who are on antiretroviral therapy and those who are virologically suppressed, and support the global expansion of TasP to accelerate the control of HIV/AIDS.
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Terapia Antirretroviral Altamente Activa , Infecciones por VIH , Profilaxis Posexposición , Servicios Preventivos de Salud , Tiempo de Tratamiento , Adulto , Terapia Antirretroviral Altamente Activa/métodos , Terapia Antirretroviral Altamente Activa/estadística & datos numéricos , Colombia Británica/epidemiología , Estudios de Cohortes , Diagnóstico Precoz , Femenino , Infecciones por VIH/epidemiología , Infecciones por VIH/terapia , Humanos , Masculino , Evaluación de Procesos y Resultados en Atención de Salud , Profilaxis Posexposición/métodos , Profilaxis Posexposición/organización & administración , Servicios Preventivos de Salud/métodos , Servicios Preventivos de Salud/organización & administración , Respuesta Virológica Sostenida , Tiempo de Tratamiento/organización & administración , Tiempo de Tratamiento/normasRESUMEN
OBJECTIVE: Strict control measures under the COVID epidemic have brought an inevitable impact on ST-segment elevation myocardial infarction (STEMI)'s emergency treatment. We investigated the impact of the COVID on the treatment of patients with STEMI undergoing primary PCI. METHODS: In this single center cohort study, we selected a time frame of 6 month after declaration of COVID-19 infection (Jan 24-July 24, 2020); a group of STEMI patients in the same period of 2019 was used as control. Finally, a total of 246 STEMI patients, who were underwent primary PCI, were enrolled into the study (136 non COVID-19 outbreak periods and 110 COVID-19 outbreak periods). The impact of COVID on the time of symptom onset to the first medical contact (symptom-to-FMC) and door to balloon (D-to-B) was investigated. Moreover, the primary outcome was in-hospital major adverse cardiac events (MACE), defined as a composite of cardiac death, heart failure and malignant arrhythmia. RESULTS: Compared with the same period in 2019, there was a 19% decrease in the total number of STEMI patients undergoing primary PCI at the peak of the pandemic in 2020. The delay in symptom-to-FMC was significantly longer in COVID Outbreak period (180 [68.75, 342] vs 120 [60,240] min, P = 0.003), and the D-to-B times increased significantly (148 [115-190] vs 84 [70-120] min, P < 0.001). However, among patients with STEMI, MACE was similar in both time periods (18.3% vs 25.7%, p = 0.168). On multivariable analysis, COVID was not independently associated with MACE; the history of diabetes, left main disease and age>65 years were the strongest predictors of MACE in the overall population. CONCLUSIONS: The COVID pandemic was not independently associated with MACE; suggesting that active primary PCI treatment preserved high-quality standards even when challenged by a severe epidemic. CLINICAL TRIAL REGISTRATION: URL: https://ClinicalTrials.gov Unique identifier: NCT04427735.
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COVID-19/prevención & control , Intervención Coronaria Percutánea/estadística & datos numéricos , Infarto del Miocardio con Elevación del ST/terapia , Anciano , Beijing/epidemiología , COVID-19/complicaciones , COVID-19/transmisión , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Intervención Coronaria Percutánea/tendencias , Estudios Retrospectivos , Infarto del Miocardio con Elevación del ST/epidemiología , Factores de Tiempo , Tiempo de Tratamiento/normas , Tiempo de Tratamiento/estadística & datos numéricos , Resultado del TratamientoRESUMEN
OBJECTIVES: To evaluate the association between low left ventricular ejection fraction (LVEF), complication rescue, and long-term survival after isolated coronary artery bypass grafting. METHODS: National cohort study of patients who underwent isolated coronary artery bypass grafting (2000-2016) using Veterans Affairs Surgical Quality Improvement Program data. Left ventricular ejection fraction was categorized as ≥35% (n = 55,877), 25%-34% (n = 3893), or <25% (n = 1707). Patients were also categorized as having had no complications, 1 complication, or more than 1 complication. The association between LVEF, complication rescue, and risk of death was evaluated with multivariable Cox regression. RESULTS: Among 61,477 patients, 6586 (10.7%) had a perioperative complication and 2056 (3.3%) had multiple complications. Relative to LVEF ≥35%, decreasing ejection fraction was associated with greater odds of complications (25%-34%, odds ratio, 1.30 [1.18-1.42]; <25%, odds ratio, 1.65 [1.43-1.92]). There was a dose-response relationship between decreasing LVEF and overall risk of death (≥35% [ref]; 25%-35%, hazard ratio, 1.46 [1.37-1.55]; <25%, hazard ratio, 1.68 [1.58-1.79]). Among patients who were rescued from complications, there were decreases in 10-year survival, regardless of LVEF. Among those rescued after multiple complications, LVEF was no longer associated with risk of death. CONCLUSIONS: While decreasing LVEF is associated with post-coronary artery bypass grafting complications, patients rescued from complications have worse long-term survival, regardless of left ventricular function. Prevention and timely treatment of complications should remain a focus of quality improvement initiatives, and future work is needed to mitigate their long-term detrimental impact on survival.
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Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria , Efectos Adversos a Largo Plazo , Complicaciones Posoperatorias , Disfunción Ventricular Izquierda , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/métodos , Enfermedad de la Arteria Coronaria/complicaciones , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/fisiopatología , Enfermedad de la Arteria Coronaria/cirugía , Intervención Médica Temprana/normas , Femenino , Humanos , Efectos Adversos a Largo Plazo/diagnóstico , Efectos Adversos a Largo Plazo/mortalidad , Efectos Adversos a Largo Plazo/fisiopatología , Efectos Adversos a Largo Plazo/prevención & control , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/fisiopatología , Complicaciones Posoperatorias/terapia , Servicios Preventivos de Salud , Mejoramiento de la Calidad , Medición de Riesgo , Volumen Sistólico , Análisis de Supervivencia , Tiempo de Tratamiento/normas , Estados Unidos , United States Department of Veterans Affairs , Disfunción Ventricular Izquierda/complicaciones , Disfunción Ventricular Izquierda/diagnóstico , Disfunción Ventricular Izquierda/fisiopatología , Disfunción Ventricular Izquierda/terapiaRESUMEN
OBJECTIVE: To examine whether there is an association between prehospital transfer distance and surgical mortality in emergency thoracic aortic surgery. METHODS: A retrospective cohort study using a national clinical database in Japan was conducted. Patients who underwent emergency thoracic aortic surgery from January 1, 2014, to December 31, 2016, were included. Patients with type B dissection were excluded. A multilevel logistic regression analysis was performed to examine the association between prehospital transfer distance and surgical mortality. In addition, an instrumental variable analysis was performed to address unmeasured confounding. RESULTS: A total of 12,004 patients underwent emergency thoracic aortic surgeries at 495 hospitals. Surgical mortality was 13.8%. The risk-adjusted mortality odds ratio for standardized distance (mean 12.8 km, standard deviation 15.2 km) was 0.94 (95% confidence interval, 0.87-1.01; P = .09). Instrumental variable analysis did not reveal a significant association between transfer distance and surgical mortality as well. CONCLUSIONS: No significant association was found between surgical mortality and prehospital transfer distance in emergency thoracic aortic surgery cases. Suspected cases of acute thoracic aortic syndrome may be transferred safely to distant high-volume hospitals.
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Aorta Torácica/cirugía , Enfermedades de la Aorta , Servicios Médicos de Urgencia , Procedimientos Quirúrgicos Torácicos , Triaje , Enfermedad Aguda , Anciano , Enfermedades de la Aorta/diagnóstico , Enfermedades de la Aorta/mortalidad , Enfermedades de la Aorta/fisiopatología , Enfermedades de la Aorta/cirugía , Urgencias Médicas/epidemiología , Servicios Médicos de Urgencia/organización & administración , Servicios Médicos de Urgencia/estadística & datos numéricos , Femenino , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Hospitales de Alto Volumen , Humanos , Japón , Masculino , Evaluación de Procesos y Resultados en Atención de Salud , Estudios Retrospectivos , Ajuste de Riesgo/métodos , Factores de Riesgo , Procedimientos Quirúrgicos Torácicos/métodos , Procedimientos Quirúrgicos Torácicos/mortalidad , Procedimientos Quirúrgicos Torácicos/estadística & datos numéricos , Tiempo de Tratamiento/normas , Tiempo de Tratamiento/estadística & datos numéricos , Triaje/organización & administración , Triaje/normasAsunto(s)
Recien Nacido Prematuro/fisiología , Nutrición Parenteral , Tiempo de Tratamiento , Edad Gestacional , Humanos , Recién Nacido , Nutrición Parenteral/efectos adversos , Nutrición Parenteral/métodos , Nutrición Parenteral/normas , Selección de Paciente , Perinatología/métodos , Perinatología/normas , Perinatología/tendencias , Medición de Riesgo , Análisis de Supervivencia , Tiempo de Tratamiento/normas , Tiempo de Tratamiento/tendenciasRESUMEN
BACKGROUND: Timing of extremity fracture fixation in patients with an associated major vascular injury remains controversial. Some favor temporary fracture fixation before definitive vascular repair to limit potential graft complications. Others advocate immediate revascularization to minimize ischemic time. The purpose of this study was to evaluate the timing of fracture fixation on outcomes in patients with concomitant long bone fracture and major arterial injury. METHODS: Patients with a combined long bone fracture and major arterial injury in the same extremity requiring operative repair over 11 years were identified and stratified by timing of fracture fixation. Vascular-related morbidity (rhabdomyolysis, acute kidney injury, graft failure, extremity amputation) and mortality were compared between patients who underwent fracture fixation prerevascularization (PRE) or postrevascularization (POST). RESULTS: One hundred four patients were identified: 19 PRE and 85 POST. Both groups were similar with respect to age, sex, Injury Severity Score, admission base excess, 24-hour packed red blood cells, and concomitant venous injury. The PRE group had fewer penetrating injuries (32% vs. 60%, p = 0.024) and a longer time to revascularization (9.5 vs. 5.8 hours, p = 0.0002). Although there was no difference in mortality (0% vs. 2%, p > 0.99), there were more vascular-related complications in the PRE group (58% vs. 32%, p = 0.03): specifically, rhabdomyolysis (42% vs. 19%, p = 0.029), graft failure (26% vs. 8%, p = 0.026), and extremity amputation (37% vs. 13%, p = 0.013). Multivariable logistic regression identified fracture fixation PRE as the only independent predictor of graft failure (odds ratio, 3.98; 95% confidence interval, 1.11-14.33; p = 0.03) and extremity amputation (odds ratio, 3.924; 95% confidence interval, 1.272-12.111; p = 0.017). CONCLUSION: Fracture fixation before revascularization contributes to increased vascular-related morbidity and was consistently identified as the only modifiable risk factor for both graft failure and extremity amputation in patients with a combined long bone fracture and major arterial injury. For these patients, delaying temporary or definitive fracture fixation until POST should be the preferred approach. LEVEL OF EVIDENCE: Prognostic study, Level IV.
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Arterias , Extremidades , Fijación de Fractura , Isquemia , Traumatismo Múltiple , Procedimientos Quirúrgicos Vasculares , Lesiones del Sistema Vascular , Adulto , Amputación Quirúrgica/estadística & datos numéricos , Arterias/lesiones , Arterias/cirugía , Extremidades/irrigación sanguínea , Extremidades/lesiones , Extremidades/cirugía , Femenino , Fijación de Fractura/efectos adversos , Fijación de Fractura/métodos , Supervivencia de Injerto , Humanos , Isquemia/etiología , Isquemia/prevención & control , Masculino , Traumatismo Múltiple/diagnóstico , Traumatismo Múltiple/cirugía , Evaluación de Procesos y Resultados en Atención de Salud , Pronóstico , Rabdomiólisis/diagnóstico , Rabdomiólisis/etiología , Rabdomiólisis/prevención & control , Ajuste de Riesgo/métodos , Tiempo de Tratamiento/normas , Tiempo de Tratamiento/estadística & datos numéricos , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/métodos , Procedimientos Quirúrgicos Vasculares/estadística & datos numéricos , Lesiones del Sistema Vascular/diagnóstico , Lesiones del Sistema Vascular/cirugía , Heridas Penetrantes/diagnóstico , Heridas Penetrantes/cirugíaRESUMEN
BACKGROUND: Delays in cancer diagnosis have been associated with reduced survival, decreased quality of life after treatment, and suboptimal patient experience. The objective of the study was to explore the perspectives of a group of family physicians and other specialists regarding potentially avoidable delays in diagnosing cancer, and approaches that may help expedite the process. METHODS: We conducted a qualitative study using interviews with physicians practising in primary and outpatient care settings in Alberta between July and September 2019. We recruited family physicians and specialists who were in a position to discuss delays in cancer diagnosis by email via the Cancer Strategic Clinical Network and the Alberta Medical Association. We conducted semistructured interviews over the phone, and analyzed data using thematic analysis. RESULTS: Eleven family physicians and 22 other specialists (including 7 surgeons or surgical oncologists, 3 pathologists, 3 radiologists, 2 emergency physicians and 2 hematologists) participated in interviews; 22 were male (66.7%). We identified 4 main themes describing 9 factors contributing to potentially avoidable delays in diagnosis, namely the nature of primary care, initial presentation, investigation, and specialist advice and referral. We also identified 1 theme describing 3 suggestions for improvement, including system integration, standardized care pathways and a centralized advice, triage and referral support service for family physicians. INTERPRETATION: These findings suggest the need for enhanced support for family physicians, and better integration of primary and specialty care before cancer diagnosis. A multifaceted and coordinated approach to streamlining cancer diagnosis is required, with the goals of enhancing patient outcomes, reducing physician frustration and optimizing efficiency.