Implementation of a Rapid Assessment Unit (Intake Team): Impact on Emergency Department Length of Stay

Implementation of a Rapid Assessment Unit (Intake Team): Impact on Emergency Department Length of Stay Richard S. MacKenzie, MD, David B. Burmeister, DO, Jennifer A. Brown, RN, Melissa Teitsworth, RN, BSN, Christopher J. Kita, MEd, Megan J. Dambach, DO, Shaheen Shamji, DO, Anita Kurt, PhD, RN , Susan Friend, Marna Greenberg, DO, MPH Acknowledge: Clare M. Lenhart, PhD, MPH Objective: Emergency Department (ED) crowding is an on-going formidable issue for many EDs. A Rapid Assessment Unit (RAU) is a potential solution. This process involves the use of a team approach to convert the current “series” type evaluation to a more “parallel” evaluation and treatment of patients. The RAU concept of evaluating and treating ED patients radically changes the current methods utilized in today’s standard emergency care area. The RAU concept offers a process in which the patient walks into the ED and is seen in a unit by an intake team composed of a nurse, registrar, and provider (physician assistant, nurse practitioner, or physician) that provides evaluation and emergent treatment. This removes the redundancy of a patient giving the same information several times before they are treated. Simultaneously, the team decides whether the patient would be better served by remaining seated or requires a recumbent position. This is referred to as allowing “vertical flow” versus the default “horizontal flow” where all patients recline on a stretcher whether they need it or not. Certainly, having construction that specifically supports these processes is an innovation as well (having an area where patients can be seated and remain “vertical”). The team structure itself is unique. The nurses and providers are not assigned geographically by room but rather are defined by their function. We set out to determine if the addition of the RAU process would decreases the LOS of the discharged ambulatory arrival patient. Methods: After IRB approval, this retrospective, pre- and post intervention, observational comparison study was conducted from August 2011-March 2012 at a suburban teaching hospital in central Pennsylvania with an annual ED census of approximately 54,000. The inclusion criteria were all ambulatory discharged patients. The exclusion criteria were all patients that arrived by ambulance and admitted patients. Data points captured included: time of arrival in triage , time in triage to ED entry, time of ED entry until seen by a provider, time from ED entry to discharge, total length of stay (LOS). The data were uploaded to Horizon Business Insight™ (HBI), a cumulative data manager and exported to an Microsoft excel file for analysis. Mann-Whitney U tests were used to demonstrate differences in Median LOS. All statistical tests were 2-sided; probability values \u3c0.05 were considered significant. Results: 11, 994 pre and 10814 post-RAU patients were included in analysis. Median LOS was shorter during the post-RAU period in each subcategory of LOS with the exception of the interval from being seen in the ER to discharge which is a result of provider seeing the patient earlier in the ED encounter. Results, Table 1. Conclusions: The RAU process decreases the LOS of the discharged ambulatory arrival patient and deserves further exploration as an innovative model in the ED that improves flow

MicroRNA Expression Profiling Identifies Activated B Cell Status in Chronic Lymphocytic Leukemia Cells

Chronic lymphocytic leukemia (CLL) is thought to be a disease of resting lymphocytes. However, recent data suggest that CLL cells may more closely resemble activated B cells. Using microRNA (miRNA) expression profiling of highly-enriched CLL cells from 38 patients and 9 untransformed B cells from normal donors before acute CpG activation and 5 matched B cells after acute CpG activation, we demonstrate an activated B cell status for CLL. Gene set enrichment analysis (GSEA) identified statistically-significant similarities in miRNA expression between activated B cells and CLL cells including upregulation of miR-34a, miR-155, and miR-342-3p and downregulation of miR-103, miR-181a and miR-181b. Additionally, decreased levels of two CLL signature miRNAs miR-29c and miR-223 are associated with ZAP70+ and IgVH unmutated status and with shorter time to first therapy. These data indicate an activated B cell status for CLL cells and suggest that the direction of change of individual miRNAs may predict clinical course in CLL

Potential impact of invasive alien species on ecosystem services provided by a tropical forested ecosystem: a case study from Montserrat

Local stakeholders at the important but vulnerable Centre Hills on Montserrat consider that the continued presence of feral livestock (particularly goats and pigs) may lead to widespread replacement of the reserve’s native vegetation by invasive alien trees (Java plum and guava), and consequent negative impacts on native animal species. Since 2009, a hunting programme to control the feral livestock has been in operation. However long-term funding is not assured. Here, we estimate the effect of feral livestock control on ecosystem services provided by the forest to evaluate whether the biodiversity conservation rationale for continuation of the control programme is supported by an economic case. A new practical tool (Toolkit for Ecosystem Service Site-based Assessment) was employed to measure and compare ecosystem service provision between two states of the reserve (i.e. presence and absence of feral livestock control) to estimate the net consequences of the hunting programme on ecosystem services provided by the forest. Based on this we estimate that cessation of feral livestock management would substantially reduce the net benefits provided by the site, including a 46 % reduction in nature-based tourism (from $419,000 to$228,000) and 36 % reduction in harvested wild meat (from $205,000 to$132,000). The overall net benefit generated from annual ecosystem service flows associated with livestock control in thereserve, minus the management cost, was $214,000 per year. We conclude that continued feral livestock control is important for maintaining the current level of ecosystem services provided by the reserve

ADAM17 Deletion in Thymic Epithelial Cells Alters Aire Expression without Affecting T Cell Developmental Progression

Cellular interactions between thymocytes and thymic stromal cells are critical for normal T cell development. Thymic epithelial cells (TECs) are important stromal niche cells that provide essential growth factors, cytokines, and present self-antigens to developing thymocytes. The identification of genes that mediate cellular crosstalk in the thymus is ongoing. One candidate gene, Adam17, encodes a metalloprotease that functions by cleaving the ectodomain of several transmembrane proteins and regulates various developmental processes. In conventional Adam17 knockout mice, a non-cell autonomous role for ADAM17 in adult T cell development was reported, which strongly suggested that expression of ADAM17 in TECs was required for normal T cell development. However, knockdown of Adam17 results in multisystem developmental defects and perinatal lethality, which has made study of the role of Adam17 in specific cell types difficult. Here, we examined T cell and thymic epithelial cell development using a conditional knockout approach.We generated an Adam17 conditional knockout mouse in which floxed Adam17 is deleted specifically in TECs by Cre recombinase under the control of the Foxn1 promoter. Normal T cell lineage choice and development through the canonical αβ T cell stages was observed. Interestingly, Adam17 deficiency in TECs resulted in reduced expression of the transcription factor Aire. However, no alterations in the patterns of TEC phenotypic marker expression and thymus morphology were noted.In contrast to expectation, our data clearly shows that absence of Adam17 in TECs is dispensable for normal T cell development. Differentiation of TECs is also unaffected by loss of Adam17 based on phenotypic markers. Surprisingly, we have uncovered a novel genetic link between Adam17and Aire expression in vivo. The cell type in which ADAM17 mediates its non-cell autonomous impact and the mechanisms by which it regulates intrathymic T cell development remain to be identified

PI3K Signaling in Normal B Cells and Chronic Lymphocytic Leukemia (CLL).

B cells provide immunity to extracellular pathogens by secreting a diverse repertoire of antibodies with high affinity and specificity for exposed antigens. The B cell receptor (BCR) is a transmembrane antibody, which facilitates the clonal selection of B cells producing secreted antibodies of the same specificity. The diverse antibody repertoire is generated by V(D)J recombination of heavy and light chain genes, whereas affinity maturation is mediated by activation-induced cytidine deaminase (AID)-mediated mutagenesis. These processes, which are essential for the generation of adaptive humoral immunity, also render B cells susceptible to chromosomal rearrangements and point mutations that in some cases lead to cancer. In this chapter, we will review the central role of PI3K s in mediating signals from the B cell receptor that not only facilitate the development of functional B cell repertoire, but also support the growth and survival of neoplastic B cells, focusing on chronic lymphocytic leukemia (CLL) B cells. Perhaps because of the central role played by PI3K in BCR signaling, B cell leukemia and lymphomas are the first diseases for which a PI3K inhibitor has been approved for clinical use

Breakout Session #1: ED Rapid Assessment Unit

From Breakout Session #

A Multicenter Investigation of Factors Influencing Women\u27s Participation in Clinical Trials.

OBJECTIVE: To identify factors that influence women\u27s participation in clinical research. METHODS: We administered a survey in outpatient and inpatient populations of Obstetrics and Gynecology facilities of six institutions located in four states. The survey included questions regarding any of the participant\u27s past experiences in clinical research and the factors that would influence their participation in clinical research. Analyses included descriptive statistics and a Principal Component Analysis. RESULTS: The analysis included 3,773 respondents; 2,477 (68.1%) were pregnant. The majority of participants were Caucasian (1,453, 40.2%), followed by Hispanic (933, 25.8%), African American/black (744, 20.6%), other minorities (270, 7.5%), and multiracial (212, 5.9%). Ten potential motivating factors and 10 potential barriers were assessed. The greatest motivating factor was how well research is explained (mean = 2.87) while risk of unknown side effects was the greatest barrier (mean = 3.07) for women\u27s participation in clinical trials. Among six helpful resources assessed, material in my own language was scored as the highest (mean = 2.8) in facilitating women\u27s decision to participate. For risk to the fetus/future fertility as a barrier, pregnant women\u27s score (mean = 3.25) was significantly higher than nonpregnant women\u27s score (mean = 2.37). CONCLUSIONS: Overall, the risk of unknown side effects discourages women in general, and the risk to the fetus/future fertility discourages pregnant women the most from participating in clinical trials. However, explaining a study well and providing written material in the patients\u27 own language may increase their willingness to participate