Pediatric interfacility transport effects on mortality and length of stay

Background We aimed to evaluate the effects of interfacility pediatric critical care transport response time, physician presence during transport, and mode of transport on mortality and length of stay (LOS) among pediatric patients. We hypothesized that a shorter response time and helicopter transports, but not physician presence, are associated with lower mortality and a shorter LOS. Methods Retrospective, single-center, cohort study of 841 patients (< 19 years) transported to a quaternary pediatric intensive care unit and cardiovascular intensive care unit between 2014 and 2018 utilizing patient charts and transport records. Multivariate linear and logistic regression analyses adjusted for age, diagnosis, mode of transport, response time, stabilization time, return duration, mortality risk (pediatric index of mortality-2 and pediatric risk of mortality-3), and inotrope, vasopressor, or mechanical ventilation presence on admission. Results Four hundred and twenty-eight (50.9%) patients were transported by helicopter, and 413 (49.1%) were transported by ambulance. Physicians accompanied 239 (28.4%) transports. The median response time was 2.0 (interquartile range 1.4–2.9) hours. Although physician presence increased the median response time by 0.26 hours (P = 0.020), neither physician presence nor response time significantly affected mortality, ICU length of stay (ILOS) or hospital length of stay (HLOS). Helicopter transports were not significantly associated with mortality or ILOS, but were associated with a longer HLOS (3.24 days, 95% confidence interval 0.59–5.90) than ambulance transports (P = 0.017). Conclusions These results suggest response time and physician presence do not significantly affect mortality or LOS. This may reflect the quality of pre-transport care and medical control communication. Helicopter transports were only associated with a longer HLOS. Our analysis provides a framework for examining transport workforce needs and associated costs.

Abstract 148: A Machine Learning-based Dispatch Rule for Drone-delivered Defibrillators

Introduction: Drone-delivered defibrillators may reduce response time for out-of-hospital cardiac arrest (OHCA). However, an optimal dispatch rule is not yet known. Methods: We identified all suspected OHCAs in Peel Region, Ontario, Canada from Jan. 2014 to Dec. 2019. We trained a neural network model to predict emergency medical services (EMS) response times using OHCA location, distance from responding ambulance, day of week and time of day. Instead of least-squares loss, our model optimized a loss function that penalized weighted errors in the dispatch decision (type I/II error). Assuming drones were deployed from three bases in the region, we calculated drone response time to each suspected OHCA using real drone specifications. Our dispatch rule dispatched a drone when its calculated response time was shorter than the predicted EMS response time. Response time was calculated as the minimum of the drone and EMS response times. The performance of our dispatch rule was compared on out-of-sample OHCAs using 5-fold cross validation to the baseline cases of (1) no drones, and (2) drone dispatch to every suspected OHCA. Statistical analysis on the median response times was performed using a right-tailed sign test. Results: We identified 4774 suspected OHCAs with a median historical EMS response time of 6.0 minutes. Using our dispatch rule, median response time was significantly shorter at 3.9 minutes (P<0.001). Drones were dispatched to 3803 cases (79.7%) and of those, drone response was faster than EMS in 3076 cases (80.9%). When the drone was not dispatched, it would have been slower than EMS in 856 cases (88.1%). Sending a drone to every suspected OHCA resulted in an identical median response time of 3.9 minutes (P<0.001), with drones arriving before EMS in 3191 cases (66.8%). Conclusion: A machine learning-based dispatch rule can achieve similar response times as a policy that dispatches a drone to all suspected OHCAs, while dispatching drones less frequently.

Organ responses with daratumumab therapy in previously treated AL amyloidosis

Immunoglobulin light chain amyloidosis (AL amyloidosis) involves deposition of abnormally folded light chains into a wide range of tissues causing organ dysfunction, including in the heart and kidney. Daratumumab, a CD38-targeted antibody, has recently demonstrated efficacy in producing hematologic responses in previously treated disease. However, data on survival outcomes and organ responses to daratumumab are lacking. Seventy-two patients with previously treated AL amyloidosis who received daratumumab monotherapy with dexamethasone were retrospectively evaluated. With a median follow-up of 27 months, 2-year overall survival (OS) was 86.9% (median OS, not reached) and 2-year time-to-next treatment or death (TTNT)–free survival was 62% (median TTNT, not reached). Forty of 52 evaluable patients achieved a hematologic response (77%), with &gt;60% of patients achieving a very good partial response or better; median time-to-hematologic response was 1 month. Fifty-seven patients (79%) had cardiac involvement, and 55% of evaluable patients achieved a cardiac response, with a median response time of 3.2 months among responders. Cardiac responses were associated with an improvement in OS, with landmark analysis for cardiac responses at 3 months trending toward statistical significance (100% vs 55% at 30 months, P = .051). Forty-seven patients (65%) had renal involvement, and 52% of evaluable patients achieved a renal response, with a median response time of 6 months among responders; there was no significant difference in OS between renal responders and nonresponders. This study demonstrates that daratumumab is highly effective in the treatment of previously treated AL amyloidosis, and a significant proportion of patients can achieve deep hematologic responses, as well as improvements in organ function.

P064: A randomized trial comparing telephone tree, text messaging, and instant messaging app for emergency department staff recall for disaster response

Introduction: A crucial component of a hospital's disaster plan is an efficient staff recall communication method. Many hospitals use a “calling tree” protocol to contact staff members and recall them to work. Alternative staff recall methods have been proposed and explored. Methods: An unannounced, multidisciplinary, randomized emergency department (ED) staff recall drill was conducted at night - when there is the greatest need for back-up personnel and staff is most difficult to reach. The drill was performed on December 14, 2017 at 4:00AM and involved ED staff members from three hospitals which are all part of the McGill University Health Centre (MUHC; Montreal, Quebec, Canada). Three tools were compared: manual phone tree, instant messaging application (IMA), and custom-made hospital Short Message Service (SMS) system. The key outcome measures were proportion of responses at 45 minutes and median response time. Results: One-hundred thirty-two participants were recruited. There were 44 participants in each group after randomization. In the manual phone tree group, 18 (41%) responded within 45 minutes. In the IMA group, 11 participants (25%) responded in the first 45 minutes. In the SMS group, seven participants responded in the first 45 minutes (16%). Manual phone tree was significantly better than SMS with an effect size of 25% (95% confidence interval for effect: 4.6% to 45.0%; P = .018). Conversely, there was no significant difference between manual phone tree and IMA with an effect size of 16% (95% confidence interval for effect: -5.7% to 38.0%; P = .17) There was a statistically significant difference in the median response time between the three groups with the phone tree group presenting the lowest median response time (8.5 minutes; range: 2.0 to 8.5 minutes; P = .000006). Conclusion: Both the phone tree and IMA groups had a significantly higher response rate than the SMS group. There was no significant difference between the proportion of responses at 45 minutes in the phone tree and the IMA arms. This study suggests that an IMA may be a viable alternative to the traditional phone tree method. Limitations of the study include volunteer bias and the fact that there was only one communication drill, which did not allow staff members randomized to the IMA and SMS groups to fully get familiar with the new staff recall methods.

A Randomized Trial Comparing Telephone Tree, Text Messaging, and Instant Messaging App for Emergency Department Staff Recall for Disaster Response

IntroductionA crucial component of a hospital’s disaster plan is an efficient staff recall communication method. Many hospitals use a “calling tree” protocol to contact staff members and recall them to work. Alternative staff recall methods have been proposed and explored.MethodsAn unannounced, multidisciplinary, randomized emergency department (ED) staff recall drill was conducted at night - when there is the greatest need for back-up personnel and staff is most difficult to reach. The drill was performed on December 14, 2017 at 4:00am and involved ED staff members from three hospitals which are all part of the McGill University Health Centre (MUHC; Montreal, Quebec, Canada). Three tools were compared: manual phone tree, instant messaging application (IMA), and custom-made hospital Short Message Service (SMS) system. The key outcome measures were proportion of responses at 45 minutes and median response time.ResultsOne-hundred thirty-two participants were recruited. There were 44 participants in each group after randomization. In the manual phone tree group, 18 (41%) responded within 45 minutes. In the IMA group, 11 participants (25%) responded in the first 45 minutes. In the SMS group, seven participants responded in the first 45 minutes (16%). Manual phone tree was significantly better than SMS with an effect size of 25% (95% confidence interval for effect: 4.6% to 45.0%; P=.018). Conversely, there was no significant difference between manual phone tree and IMA with an effect size of 16% (95% confidence interval for effect: −5.7% to 38.0%; P=.17) There was a statistically significant difference in the median response time between the three groups with the phone tree group presenting the lowest median response time (8.5 minutes; range: 2.0 to 8.5 minutes; P=.000006).Conclusion:Both the phone tree and IMA groups had a significantly higher response rate than the SMS group. There was no significant difference between the proportion of responses at 45 minutes in the phone tree and the IMA arms. This study suggests that an IMA may be a viable alternative to the traditional phone tree method. Limitations of the study include volunteer bias and the fact that there was only one communication drill, which did not allow staff members randomized to the IMA and SMS groups to fully get familiar with the new staff recall methods.HomierV, HamadR, LarocqueJ, ChasséP, KhalilE, FrancJM.A randomized trial comparing telephone tree, text messaging, and instant messaging app for emergency department staff recall for disaster response. Prehosp Disaster Med. 2018;33(5):471–477.

A Typology of Players: Between Instinctive and Contemplative *

A new typology of players is proposed based on the classification of actions as either instinctive or contemplative. A person’s type is the probability of him choosing a contemplative action. To test the typology, results of 10 games are analyzed. Actions in each game were classified depending on whether their response time was more or less, respectively, than the median response time of all subjects who played the game. It is argued that fast actions are more instinctive and slow actions are more contemplative. A subject’s contemplative index (CI) is defined as the proportion of games in which he chose a contemplative action. It is found that for 8 of the 10 games, the CI in the other 9 games is positively correlated with a player’s choice of a contemplative action in that game (average Spearman correlation of 9%). The CI is used to shed light on the nature of choice in five additional games.