Applying Lean: Implementation of a Rapid Triage and Treatment System

Objective: Emergency department (ED) crowding creates issues with patient satisfaction, long wait times and leaving the ED without being seen by a doctor (LWBS). Our objective was to evaluate how applying Lean principles to develop a Rapid Triage and Treatment (RTT) system affected ED metrics in our community hospital.Methods: Using Lean principles, we made ED process improvements that led to the RTT system. Using this system, patients undergo a rapid triage with low-acuity patients seen and treated by a physician in the triage area. No changes in staffing, physical space or hospital resources occurred during the study period. We then performed a retrospective, observational study comparing hospital electronic medical record data six months before and six months after implementation of the RTT system.Results: ED census was 30,981 in the six months prior to RTT and 33,926 after. Ambulance arrivals, ED patient acuity and hospital admission rates were unchanged throughout the study periods. Mean ED length of stay was longer in the period before RTT (4.2 hours, 95% confidence interval [CI] = 4.2-4.3; standard deviation [SD] = 3.9) than after (3.6 hours, 95% CI = 3.6-3.7; SD = 3.7). Mean ED arrival to physician start time was 62.2 minutes (95% CI = 61.5-63.0; SD = 58.9) prior to RTT and 41.9 minutes (95% CI = 41.5-42.4; SD = 30.9) after. The LWBS rate for the six months prior to RTT was 4.5% (95% CI = 3.1-5.5) and 1.5% (95% CI = 0.6-1.8) after RTT initiation.Conclusion: Our experience shows that changes in ED processes using Lean thinking and available resources can improve efficiency. In this community hospital ED, use of an RTT system decreased patient wait times and LWBS rates. [West J Emerg Med. 2011;12(2):184-191.

Height and timing of growth spurt during puberty in young people living with vertically acquired HIV in Europe and Thailand.

OBJECTIVE: The aim of this study was to describe growth during puberty in young people with vertically acquired HIV. DESIGN: Pooled data from 12 paediatric HIV cohorts in Europe and Thailand. METHODS: One thousand and ninety-four children initiating a nonnucleoside reverse transcriptase inhibitor or boosted protease inhibitor based regimen aged 1-10 years were included. Super Imposition by Translation And Rotation (SITAR) models described growth from age 8 years using three parameters (average height, timing and shape of the growth spurt), dependent on age and height-for-age z-score (HAZ) (WHO references) at antiretroviral therapy (ART) initiation. Multivariate regression explored characteristics associated with these three parameters. RESULTS: At ART initiation, median age and HAZ was 6.4 [interquartile range (IQR): 2.8, 9.0] years and -1.2 (IQR: -2.3 to -0.2), respectively. Median follow-up was 9.1 (IQR: 6.9, 11.4) years. In girls, older age and lower HAZ at ART initiation were independently associated with a growth spurt which occurred 0.41 (95% confidence interval 0.20-0.62) years later in children starting ART age 6 to 10 years compared with 1 to 2 years and 1.50 (1.21-1.78) years later in those starting with HAZ less than -3 compared with HAZ at least -1. Later growth spurts in girls resulted in continued height growth into later adolescence. In boys starting ART with HAZ less than -1, growth spurts were later in children starting ART in the oldest age group, but for HAZ at least -1, there was no association with age. Girls and boys who initiated ART with HAZ at least -1 maintained a similar height to the WHO reference mean. CONCLUSION: Stunting at ART initiation was associated with later growth spurts in girls. Children with HAZ at least -1 at ART initiation grew in height at the level expected in HIV negative children of a comparable age

A novel 2D analysis method to characterize individual grains using high-energy X-ray microbeam diffraction

The development of a novel 2D analysis method for high-energy X-ray diffraction measurements using a synchrotron microbeam is reported. Its application to study in situ the martensitic transformation of small individual austenite (fcc) grains embedded in a complex ferritic/bainitic/martensitic (bcc) multiphase microstructure is also reported

Martensitic transformation of individual grains in low-alloyed TRIP steels

We have performed in situ synchrotron X-ray diffraction experiments on low-alloyed multiphase TRIP steels during cooling, to monitor the martensitic transformation of individual austenite grains within the bulk material. Direct experimental evidence is presented that the stability of the austenite grains is controlled not only by the local carbon level but also by the grain size. This new quantitative information on the martensitic transformation in complex microstructures is of great importance for the design of martensite-based metallic materials.</p

Characterization of individual retained austenite grains and their stability in low-alloyed TRIP steels

In situ three-dimensional (3-D) X-ray diffraction experiments have been performed at a synchrotron source on low-alloyed multiphase TRIP steels containing 0.25 wt.% Si and 0.44 wt.% Al and produced with different bainitic holding times, in order to assess the influence of the bainitic transformation on the thermal stability of individual austenite grains with respect to their martensitic transformation. A detailed characterization of the austenite grain volume distribution at room temperature was performed as a function of the prior bainitic holding time. In addition, the martensitic transformation behaviour of individual metastable grains was studied in situ during cooling to a temperature of 100 K. Both the carbon content and the grain volume play a key role in the stability of the austenite grains below 15 μm3, while the carbon content exerts the dominant effect in the stability of the bigger grains. Measurements also suggest that the tetragonality of the thermally formed martensite is suppressed.</p

Een traumasensitief klimaat in de school:hoe doe je dat en wat levert het op voor leerlingen en leerkrachten?

Hoe ontwikkel je een traumasensitief klimaat in een school? En wat zijn de opbrengsten van een traumasensitief onderwijsklimaat voor leerkrachten en leerlingen? Het consortium Traumasensitief Onderwijs (TSO) voerde met een subsidie van het Nationaal Regieorgaan Onderwijsonderzoek (NRO) een onderzoek uit naar de implementatie van traumasensitief werken in het onderwijs

Absent cervical spine pedicle and associated congenital spinal abnormalities - a diagnostic trap in a setting of acute trauma: case report

BACKGROUND: Congenital spinal abnormalities can easily be misdiagnosed on plain radiographs. Additional imaging is warranted in doubtful cases, especially in a setting of acute trauma. Case Presentation This patient presented at the emergency unit of our university hospital after a motor vehicle accident and was sent to our radiology department for imaging of the cervical spine. Initial clinical examination and plain radiographs of the cervical spine were performed but not conclusive. Additional CT of the neck helped establish the right diagnosis. CONCLUSION: CT as a three-dimensional imaging modality with the possibility of multiplanar reconstructions allows for the exact diagnosis and exclusion of acute traumatic lesions of the cervical spine, especially in cases of doubtful plain radiographs and when congenital spinal abnormalities like absent cervical spine pedicle with associated spina bifida may insinuate severe trauma

Een traumasensitief klimaat in de school:hoe doe je dat en wat levert het op voor leerlingen en leerkrachten?

Hoe ontwikkel je een traumasensitief klimaat in een school? En wat zijn de opbrengsten van een traumasensitief onderwijsklimaat voor leerkrachten en leerlingen? Het consortium Traumasensitief Onderwijs (TSO) voerde met een subsidie van het Nationaal Regieorgaan Onderwijsonderzoek (NRO) een onderzoek uit naar de implementatie van traumasensitief werken in het onderwijs