title: Sources of Delay in the Acute Limb Ischemia Patient Pathway.
abstract: BACKGROUND
  Acute limb ischemia (ALI) continues to pose a significant challenge to clinicians and is associated with an unacceptably high rate of morbidity and mortality. Despite its time critical nature, little is known regarding the delays encountered during the patient pathway. The aim of this study was to identify sources of delay in the patient pathway at our institution.
  
  
  METHODS
  Sixty-seven cases of ALI of the lower extremities from 66 patients, who had presented to our center between May 2003 and April 2014, were identified for retrospective analysis. Data were retrieved from the patient records, discharge summaries and hospital laboratory, emergency department and radiology databases.
  
  
  RESULTS
  Median time from onset of symptom to arrival at our institution was 11.35 hr (interquartile range [IQR] 6.27-72). Median cumulative time taken from arrival to vascular team review was 40 min (22.5-120), to imaging being performed was 4.75 hr (2.42-17.25), and to intervention being performed was 10.2 hr (4-31). There were significantly longer delays to presentation in those transferred from inpatient beds as compared with those transferred from the emergency department of other hospitals (66 hr [10.3-98] vs. 8 hr [5.6-14.9], P = 0.007). In total, 84.6% of patients underwent preoperative arterial imaging. Time taken from arrival to diagnostic arterial imaging was significantly longer in patients presenting out-of-ours (15 hr [6.5-20.75]) as compared with patients presenting in-hours (3.5 hr [2-6.5], P = 0.014) or during the weekend (2 hr [2-3], P = 0.022). Time from presentation to intervention was significantly shorter in patients presenting over the weekend (3.9 hr [2.6-5.1]) as compared with those presenting in-hours (14.2 hr [6.2-29], P = 0.006) and out-of-hours (16 hr [10-33], P = 0.021). Out-of-hours, a significant portion of the delay, was attributable to imaging (median time to imaging 15 hr).
  
  
  CONCLUSIONS
  This study demonstrates the systematic nature of delays in the patient pathway from onset of symptoms to treatment. Several factors including time to patient presentation and time to imaging and delays in timely transfer to an appropriate facility contribute to this. Strategies need to be deployed to reduce time to revascularization.
authors.affiliation: Department of Vascular Surgery, Imperial College School of Medicine, Hammersmith Hospital, London, UK. Electronic address: pn106@imperial.ac.uk.
authors.forename: Pasha
authors.initials: P
authors.lastname: Normahani
authors.affiliation: Department of Vascular Surgery, Imperial College School of Medicine, Hammersmith Hospital, London, UK.
authors.forename: Nigel J
authors.initials: NJ
authors.lastname: Standfield
authors.affiliation: Department of Vascular Surgery, Imperial College School of Medicine, Hammersmith Hospital, London, UK.
authors.forename: Usman
authors.initials: U
authors.lastname: Jaffer
mesh_terms: D000208:Acute Disease; D039602:After-Hours Care / Q000458:organization & administration*; D000368:Aged; D000369:Aged, 80 and over; D019091:Critical Pathways / Q000458:organization & administration*; D057210:Delayed Diagnosis; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D004526:Efficiency; D017598:Efficiency, Organizational; D004636:Emergency Service, Hospital / Q000458:organization & administration; D005260:Female; D006801:Humans; D007511:Ischemia / Q000000981:diagnostic imaging / Q000628:therapy*; D008131:London; D008297:Male; D008875:Middle Aged; D010343:Patient Admission; D010360:Patient Transfer / Q000458:organization & administration; D011237:Predictive Value of Tests; D017064:Process Assessment, Health Care; D012189:Retrospective Studies; D013997:Time Factors; D017748:Time Management / Q000458:organization & administration*; D061665:Time-to-Treatment / Q000458:organization & administration*; D016896:Treatment Outcome; D057188:Workflow