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Background Ambulance off-load delays in transferring patient care to emergency departments (EDs) are increasingly common, but it is unclear whether clinical outcomes are impacted. Methods Population-based cohort study of ambulance attendances for non-traumatic chest pain transported to ED in Victoria, Australia (1/1/2015–30/6/2019) excluding patients transported to hospital with “lights and sirens” or triaged as ED category 1. Multivariable models were used to assess the relationship between ambulance off-load times and 30-day mortality and ambulance re-attendance for chest pain. Results The study included 213,544 ambulance attendances for chest pain (mean age 62 [SD 18] years; 51% female). Median ambulance off-load times increased across the study period from 21 minutes (interquartile range [IQR] 15–30) in 2015 to 24 minutes (IQR 17–37) in 2019. Patients were divided into tertiles according to off-load times with 69,247 patients included in tertile 1 (0–17 minutes), 73,109 patients in tertile 2 (18–28 minutes), and 71,188 patients in tertile 3 (>28 minutes). In multivariable models, ambulance off-load delays were associated with higher unadjusted and adjusted rates of 30-day mortality (1.57% tertile 3 vs. 1.29% tertile 1, adjusted risk difference 0.28% [95% CI 0.16% - 0.42%], p Conclusions Delays in ambulance off-load times appear to be associated with increased mortality and ambulance re-attendance risk among chest pain cohorts. This study has important policy implications given the increasing frequency of off-load delays in many healthcare settings. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Alfred health

Background Previous studies examining temporal variation in cardiovascular care have largely been limited to assessing weekend and after-hours effects whereby those presenting on the weekend or after-hours have a poorer outcome. However, emerging evidence suggests more complex patterns in patterns and outcomes may exist. Purpose We aimed to determine patterns of temporal variation in chest pain presentations and subsequent health-care quality and outcomes. Methods This was an observational, prospective-cohort study of adult patients aged 18 and over who were attended by emergency medical services for non-traumatic chest pain between 1 January 2015 and 30 June 2019 in Victoria, Australia. Major exclusion criteria included pre-hospital diagnosis of ST elevation myocardial infarction or an out of hospital cardiac arrest. The exposure variable was time of day and day of week stratified into 168 hourly time periods. The primary outcome measure was 30-day mortality. Results The study cohort comprised 196,365 ambulance attendances for acute non-traumatic chest pain; mean age 62.4 years (SD 18.3) and 99,497 (50.7%) females. Three temporal patterns were observed for chest pain presentations (Figure 1): (1) a diurnal pattern with a sharp increase in presentations from 8 am, peaking around midday, before decreasing into late evening with a nadir between 3–4 am, (2) a weekend effect where Saturday and Sunday had a relatively lower rate of presentations compared to during the week, and (3) a Monday – Sunday gradient where more presentations were likely earlier in the week, than later. Six patterns were identified across pre-hospital and hospital key performance indicators (KPI) (diurnal, in/after-hours, weekend effect, Monday – Sunday gradient, a peak period and morning vs afternoon/evening effect. Risk of 30-day mortality was associated with weekend presentation (OR 1.15, 95% CI 1.06–1.24, p=0.001) and morning presentation between midnight and midday (OR 1.17, 95% CI 1.09–1.25, p Conclusion Chest pain presentations, care quality and outcomes demonstrate complex temporal variation beyond the already established weekend and after-hours effect. Such relationships should be considered during resource allocation and quality improvement programs in order to improve treatment quality across all days and times of the week. Funding Acknowledgement Type of funding sources: None.

1 South Western Sydney Clinical School, The University of NSW, Sydney, NSW, Australia 2 Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia 3 Royal Brisbane Hospital, Herston, Qld, Australia 4 Cardiology Department, Auckland City Hospital, Auckland, New Zealand 5 Cardiology Department, Royal Perth Hospital, WA, Australia 6 The Dunedin School of Medicine, University of Otago, New Zealand 7 The George Institute, University of Sydney, NSW, Australia 8 Department of Cardiology, Flinders University, Bedford Park, SA, Australia 9 CardiologyDepartment,University ofWesternAustralia,WA, Australia 10 CardiacClinicalNetwork,Department ofHealth,Melbourne, Vic, Australia 11 NSW Agency for Clinical Innovation, Chatswood, NSW, Australia 12 Queensland Department of Health, QLD, Australia 13 Cardiology Department, Waikato Hospital, Hamilton, New Zealand 14 Cardiology Concord Hospital, Sydney, NSW, Australia

Objective: To determine health related quality of life (HRQoL), functional status and re-admissions in patients 80 years and older three months after cardiac surgery Methods: Pilot prospective cohort study. Primary outcome measure: Change in HRQoL scores between baseline and three months following cardiac surgery Results: Sixty-three cardiac surgery patients were enrolled. The most frequent surgical procedures were CABG in 27 (43%), CABG + AVR/MVR in 18 (29%), AVR/MVR in 16 (25%). 61 (97%) were elective. Mean (SD) age was 83.2 (2.5) years, 56% were men, and mean (SD) length of hospital stay was 13.4 (5.9) days. Baseline self-reported co-morbidities included hypertension in 39 (62%), osteoarthritis in 27 (43%) and back pain in 21 (33%). and prosthetic heart valves with a significant risk of complications if treatment is delayed. Method: A retrospective analysis of 191 patients revealed nine patients who underwent valve replacement at The Townsville Hospital from 2008 until March 2011 with acute infective endocarditis. The outcome measures were native/prosthetic valve, indication for surgery, timing to surgery, and necessity for pre-surgical coronary angiogram. Results: A total of nine patients underwent valve replacement for active infective endocarditis. The average time to surgery fromonset of symptomswas 21.8 dayswith seven patients presenting to a peripheral centre. Themost common complication prior to surgical intervention was septic emboli (55%) followedbyheart failure (44%).Native valve endocarditis occurred in 66% of cases and surgery was performed on average 23.6.days after the onset of symptoms. Prosthetic valve endocarditiswas found in 33% and surgery was performed on an average of 18.3 days. None of the patients underwent cardiac catheterisation prior to surgery. One patients died following re-do valve surgery. Conclusion: Infective endocarditis requiring surgical managementwasmore common innative valveswith time to diagnosis being longer, compared to prosthetic valve endocarditis. Barriers to early surgery included late presentation to hospital and the need for transfer to a tertiary