Looking out for one another First Responder Physiological Monitoring (Preprint)

UNSTRUCTURED The pandemic had shed light on healthcare burnout and stress throughout the healthcare workforce even more so the First Responder. First responders experience significant physiological stress during response operations and face exposure to a myriad of hazards. Miniaturized, wearable sensors attached to or carried by respond- ers can provide incident command with information about an in- dividual’s health status and specific threats and hazards at the in- cident scene. Improved awareness of these factors helps incident command make decisions that increase the safety of responders and the population. Blended with new advancements in the internet of things and remote care, we are best to look out for one another. Rapid response services like the physician response service at Barts Health NHS trust in east London can offer a new model of working we’re we can look after one another.

Remind Me Again: Physician Response to Web Surveys: The Effect of Email Reminders Across 11 Opinion Survey Efforts at the American Board of Internal Medicine from 2017 to 2019

For survey researchers, physicians in the United States are a difficult-to-reach subgroup. The purpose of this study is to quantify the effect of email reminders on web-based survey response rates targeting physicians. We conducted a retrospective analysis of 11 American Board of Internal Medicine surveys from 2017 to 2019. We compute aggregate response rates for the periods between weekly email contacts across the 11 surveys, while controlling for survey time to complete, physician age, gender, region, board certification status, and initial exam performance. The overall predicted response rate after six weekly email contacts was 23.7%, 95% CI: (17.1%, 33.0%). Across the 11 surveys, we found response rate for the first period to be 8.9%, 95% CI: (6.5%, 12.2%). We observed a 50% decrease in response from the first to the second period, which had a 4.4%, 95% CI: (3.2%, 6.2%), response rate. The third and fourth response periods yielded similar response rates of 3.0%, 95% CI: (2.3%, 3.9%) and 3.3%, 95%CI: (2.4%, 4.6%), respectively. The fifth and sixth response periods yielded similar response rates of 2.2%, 95%CI: (1.5%, 3.3%) and 1.9%, 95% CI: (1.3%, 2.7%), respectively. The results were further stratified into different levels of participant survey interest, and are helpful for cost and sample size considerations when designing a physician survey.

Delivering Community Emergency Medicine during the COVID-19 pandemic: the Physician Response Unit

The COVID-19 pandemic has presented significant challenges to services providing emergency care, in both the community and hospital setting. The Physician Response Unit (PRU) is a Community Emergency Medicine model, working closely with community, hospital and pre-hospital services. In response to the pandemic, the PRU has been able to rapidly introduce novel pathways designed to support local emergency departments (EDs) and local emergency patients. The pathways are (1) supporting discharge from acute medical and older people’s services wards into the community; (2) supporting acute oncology services; (3) supporting EDs; (4) supporting palliative care services. Establishing these pathways have facilitated a number of vulnerable patients to access patient-focussed and holistic definitive emergency care. The pathways have also allowed EDs to safely discharge patients to the community, and also mitigate some of the problems associated with trying to maintain isolation for vulnerable patients within the ED. Community Emergency Medicine models are able to reduce ED attendances and hospital admissions, and hence risk of crowding, as well as reducing nosocomial risks for patients who can have high-quality emergency care brought to them. This model may also provide various alternative solutions in the delivery of safe emergency care in the postpandemic healthcare landscape.

Factors associated with physician decision making on withholding cardiopulmonary resuscitation in prehospital medicine

This study seeks to identify factors that are associated with decisions of prehospital physicians to start (continue, if ongoing) or withhold (terminate, if ongoing) CPR in patients with OHCA. We conducted a retrospective study using anonymised data from a prehospital physician response system. Data on patients attended for cardiac arrest between January 1st, 2010 and December 31st, 2018 except babies at birth were included. Logistic regression analysis with start of CPR by physicians as the dependent variable and possible associated factors as independent variables adjusted for anonymised physician identifiers was conducted. 1525 patient data sets were analysed. Obvious signs of death were present in 278 cases; in the remaining 1247, resuscitation was attempted in 920 (74%) and were withheld in 327 (26%). Factors significantly associated with higher likelihood of CPR by physicians (OR 95% CI) were resuscitation efforts by EMS before physician arrival (60.45, 19.89–184.29), first monitored heart rhythm (3.07, 1.21–7.79 for PEA; 29.25, 1.93–442. 51 for VF / pVT compared to asystole); advanced patient age (modelled using cubic splines), physician response time (0.92, 0.87–0.97 per minute) and malignancy (0.22, 0.05–0.92) were significantly associated with lower odds of CPR. We thus conclude that prehospital physicians make decisions to start or withhold resuscitation routinely and base those mostly on situational information and immediately available patient information known to impact outcomes.

Abstract P146: Assessment of Telestroke Sub-Events and Their Contribution to Door-To-Needle Time in a Telestroke Network

Introduction: Data remains scarce on which telestroke related sub-events (component parts/time intervals) are associated with delays in door-to-needle (DTN) time and goals for each telestroke sub-event. We aimed to assess the telestroke sub-events that contribute to DTN. After establishing set goals for each sub-event, we further evaluated the odds of DTN within 45 minutes if sub-event goals were achieved. Methods: We retrospectively analyzed prospectively collected data from a hub-and-spoke model telestroke network from January 2017 to September 2019. To determine which sub-events significantly contributed to DTN time, a sequential multiple regression analysis was performed. We entered covariates (age, sex, time of telestroke [day or night], NIHSS, average number of telestroke consults at a given site) in the first block followed by sub-events (door-to-telestroke request, door-to-CT, request-to-page, stroke physician response time, telestroke phone-to-video, video duration prior to needle and video completion-to-needle) in the second block. Logistic regression models were performed to estimate the odds of achieving a DTN within 45 minutes if sub-event goals were achieved. Results: During the study, 3361 telestrokes were completed and 306 (9.1%) patients received IV thrombolytics. After exclusions, 253 patients treated with IV thrombolytics were included. Five sub-events contributed to DTN time above and beyond the nuisance variables: door-to-telestroke request, stroke physician response time, telestroke phone-to-video, video duration prior to needle, and video completion-to-needle; each p <0.001. DTN time within 45 minutes was more likely when door-to-telestroke request <10 minutes (OR=12.30, 95%CI 3.47-43.65), video completion to needle <1 minute (OR=4.21, 95%CI 1.45-12.20) and telestroke phone-to-video <7 minutes (OR=5.24, 95%CI 1.41-19.49). Conclusions: Telestroke sub-events involving door-to-telestroke request, stroke physician response, telestroke phone-to-video, video duration prior to needle, and video completion-to-needle significantly contribute to DTN time. Successful achievement of sub-event goals was related to greater likelihood of administration of thrombolytic therapy within 45 minutes.

P132: Optimizing a physician surge protocol to address emergency department wait times during times of increased patient demand

Background: Emergency Department overcrowding remains a significant problem. Interventions have often focused on areas external to the ED, with patient flow in the ED receiving less attention. Efforts to address ED flow are complicated by daily fluctuations in patient volume and acuity. Our local protocol brings in additional physicians when internal metrics indicate patient demand can't be met by current physician resources (a ‘surge’ period). However, anecdotal evidence suggests a lack of satisfaction and efficacy. We therefore undertook a project to improve our local management of these surge periods. Aim Statement: To improve the effectiveness of an ED Physician Surge Protocol to allow for a physician scheduling strategy that is reflective of the needs of the ED. Measures & Design: This project consists of 3 phases. Phase 1 was an analysis of current surge metrics (including frequency, temporal patterns and physician response), with concurrent literature search to identify any best practices or easily addressable protocol changes, with first planned PDSA cycle. Phase 2 is a mixed methods survey of local staff to identify barriers and enablers of our current protocol, concurrent with a national survey of current practices. Phase 3 will be the implementation of a revised protocol, followed by a second mixed methods survey and analysis of metrics of interest. Evaluation/Results: Analysis of surge data (Oct 2018-Oct 2019) demonstrated a high volume of surges per month (78.7 +/- 10.9), highest at Foothills Medical Centre (94.3). Across all sites, afternoon periods had highest frequency of surges (absolute peak 1400 - 1500) with a secondary peak 2200–2300, both peaks occurring most frequently on weekends (Fri-Sun) However, physician response to surge calls was < 10% (5.8-9.1%), with no discernable temporal pattern, even accounting for the significant number of automatic surge calls cancelled by clinicians. Analysis of data, in addition to literature review and engagement with senior administration suggested no immediate protocol changes, therefore project moved to 2nd phase. This phase is currently in progress, with planned analysis using Pareto Chart methodology. Discussion/Impact: Our initial data clearly demonstrates that current procedures are inadequate to address this ongoing issue, with no readily apparent solutions. Analysis of local barriers and enablers is currently underway, in addition to a national survey, with the results expected to inform an extensive redesign of current procedures.