Impact of Scribes with Flow Coordination Duties on Throughput in an Academic Emergency Department

Introduction: With the increasing influence of electronic health records in emergency medicine came concerns of decreasing operational efficiencies. Particularly worrisome was increasing patient length of stay (LOS). Medical scribes were identified to be in a good position to quickly address barriers to treatment delivery and patient flow. The objective of this study was to investigate patient LOS in the mid- and low-acuity zones of an academic emergency department (ED) with and without medical scribes.Methods: A retrospective cohort study compared patient volume and average LOS between a cohort without scribes and a cohort after the implementation of a scribe-flow coordinator program. Patients were triaged to the mid-acuity Vertical Zone (primarily Emergency Severity Index [ESI] 3) or low-acuity Fast Track (primarily ESI 4 and 5) at a tertiary academic ED. Patients were stratified by treatment zone, acuity level, and disposition.Results: The pre-intervention and post-intervention periods included 8900 patients and 9935 patients, respectively. LOS for patients discharged from the Vertical Zone decreased by 12 minutes from 235 to 223 minutes (p<0.0001, 95% confidence interval [CI], -17,-7) despite a 10% increase in patient volume. For patients admitted from the Vertical Zone, volume increased 13% and LOS remained almost the same, increasing from 225 to 228 minutes (p=0.532, 95% CI, -6,12). For patients discharged from the Fast Track, volume increased 14% and LOS increased six minutes, from 89 to 95 minutes (p<0.0001, 95% CI, 4,9). Predictably, only 1% of Fast Track patients were admitted.Conclusion: Despite substantially increased volume, the use of scribes as patient flow facilitators in the mid-acuity zone was associated with decreased LOS. In the low-acuity zone, scribes were not shown to be as effective, perhaps because rapid patient turnover required them to focus on documentation

Private warehouse investment strategies in small versus large manufacturing firms

The research reported in this manuscript empirically compares the private warehouse investment strategies of small and large manufacturing firms. Mail surveys were administered to independent samples of small and large United States manufacturing firms. This research is based on a series of identically worded questions administered to both samples. Data was factor analyzed and cluster analyzed to identify three private warehouse investment strategies for small and large firms and two strategies for large firms. Analyses of three independent variables further evaluated differences in private warehouse investment strategies. Finally, the warehouse mix of small and of large firms was compared. This study identified specific private warehouse investment strategies, and warehouse mixes, in small and large United States manufacturing firms. Small firms were found to be less likely to use formal capital budgeting techniques and were less likely to consider strategic issues than large firms. Small firms were also found to be more likely to use private warehousing than large firms. This research increases the awareness of differences in logistics practice between small and large manufacturing firms and suggests that generalizations regarding logistics strategy should be approached with caution

A study of logistics strategies in small versus large U.S. manufacturing firms

The research reported in this manuscript empirically compares the similarities and differences of logistics strategies for small and large manufacturing firms. The hypotheses focus on whether there are significant differences between logistics strategies of small and large manufacturing firms and whether logistics strategy outcomes differ. The findings indicate that there are many similarities but differences do exist. The results identify dimensions of logistics strategy and assess their impact on logistics coordination effectiveness, customer service commitment, and company/division competitive responsiveness

A longitudial study of private warehouse investment strategies

This article revisits private warehouse investment decision making, a topic previously examined in 1989 by McGinnis, Kohn, and Myers (1990). Since then there has been a substantial amount of discussion regarding the scope and nature of logistics /supply chain management. In particular the roles of private, contract, and public warehousing has been discussed, increased emphasis on financial performance and strategic decision making may have altered the criteria for investment decisions in private warehousing, increased coordination of supply chains may have altered the relative importance of private, contract, and private warehousing, and increasing emphasis on controlling inventory investment may have shifted inventory responsibilities onto suppliers and customers. Empirical data was collected in 1999and 2008 regarding warehouse investment decisions in large United State manufacturing firms. This research focused on private warehouse investment decisions, topics that might affect those decisions, and the mix of private, contract, public, and other warehouse options. The results of the 1999 and 2008 data were compared to the earlier findings reported by McGinnis, Kohn, and Myers. Changes in private warehouse investment strategies, the roles of market /product mix uncertainties and availability of for-hire warehouse providers, and changes in warehouse mix were examined. Implications for practitioners, teachers, and researchers of transportation, supply chain management, logistics, and warehousing are discussed

An Integral Kernel for Weakly Pseudoconvex Domains

A new explicit construction of Cauchy-Fantappi\'e kernels is introduced for an arbitrary weakly pseudoconvex domain with smooth boundary. While not holomorphic in the parameter, the new kernel reflects the complex geometry and the Levi form of the boundary. Some estimates are obtained for the corresponding integral operator, which provide evidence that this kernel and related constructions give useful new tools for complex analysis on this general class of domains

Hormander class of pseudo-differential operators on compact Lie groups and global hypoellipticity

In this paper we give several global characterisations of the Hormander class of pseudo-differential operators on compact Lie groups. The result is applied to give criteria for the ellipticity and the global hypoellipticity of pseudo-differential operators in terms of their matrix-valued full symbols. Several examples of the first and second order globally hypoelliptic differential operators are given. Where the global hypoelliptiticy fails, one can construct explicit examples based on the analysis of the global symbols.Comment: 20 page

Ultrastructural Changes Accompanying the Mechanical Deformation of Bone Tissue: A Raman Imaging Study

Raman spectroscopy and imaging are known to be valuable tools for the analysis of bone, the determination of protein secondary structure, and the study of the composition of crystalline materials. We have utilized all of these attributes to examine how mechanical loading and the resulting deformation affects bone ultrastructure, addressing the hypothesis that bone spectra are altered, in both the organic and inorganic regions, in response to mechanical loading/deformation. Using a cylindrical indenter, we have permanently deformed bovine cortical bone specimens and investigated the ultrastructure in and around the deformed areas using hyperspectral Raman imaging coupled with multivariate analysis techniques. Indent morphology was further examined using scanning electron microscopy. Raman images taken at the edge of the indents show increases in the low-frequency component of the amide III band and high-frequency component of the amide I band. These changes are indicative of the rupture of collagen crosslinks due to shear forces exerted by the indenter passing through the bone. However, within the indent itself no evidence was seen of crosslink rupture, indicating that only compression of the organic matrix takes place in this region. We also present evidence of what is possibly a pressure-induced structural transformation occurring in the bone mineral within the indents, as indicated by the appearance of additional mineral factors in Raman image data from indented areas. These results give new insight into the mechanisms and causes of bone failure at the ultrastructural level.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/42363/1/30720166.pd

A genetic record of population isolation in pocket gophers during Holocene climatic change.

ABSTRACT A long-standing question in Quaternary paleontology is whether climate-induced, population-level phenotypic change is a result of large-scale migration or evolution in isolation. To directly measure genetic variation through time, ancient DNA and morphologic variation was measured over 2,400 years in a Holocene sequence of pocket gophers (Thomomys talpoides) from Lamar Cave, Yellowstone National Park, Wyoming. Ancient specimens and modern samples collected near Lamar Cave share mitochondrial cytochrome b sequences that are absent from adjacent localities, suggesting that the population was isolated for the entire period. In contrast, diastemal length, a morphologic character correlated with body size and nutritional level, changed predictably in response to climatic change. Our results demonstrate that small mammal populations can experience the long-term isolation assumed by many theoretical models of microevolutionary change

Measuring velocity of sound with nuclear resonant inelastic x-ray scattering

Nuclear resonant inelastic x-ray scattering is used to measure the projected partial phonon density of states of materials. A relationship is derived between the low-energy part of this frequency distribution function and the sound velocity of materials. Our derivation is valid for harmonic solids with Debye-like low-frequency dynamics. This method of sound velocity determination is applied to elemental, composite, and impurity samples which are representative of a wide variety of both crystalline and noncrystalline materials. Advantages and limitations of this method are elucidated