Long-Term Sustainment of Rapid Improvement Events: A Case Study in “Room Readiness”

Shifting payment models from fee for service (FFS) to pay for performance (P4P) have fundamentally changed the environment of healthcare administration in the United States (Center for Medicaid and Medicare Services (CMS), 2011). Due to this shift, there has been an increase in demand for tracking and improving quality measures to ensure not only patient safety, but optimization of utilization. Constraints on resources and capacity, coupled with increasing safety measures has developed a new study of patient flow (Miró, Sánchez, Espinosa, et al., 2003). Decreasing patient room turnover times has the potential to maximize utilization while ensuring patient safety and quality (Dyrda, 2012). LEAN and A3 Methodology were applied to create a process improvement initiative at a 500-bed regional medical center (RMC). Using a Rapid Improvement Event (RIE), efforts were made to identify gaps and improve processes to address issues which prevented patients from being in the right place, for the appropriate amount of time, and patient rooms cleaned in a timely manner. These gaps prevented adequate patient flow in the RMC. After tracking the implemented improvements for a year, the RMC ceased following the newly designed process. This study examines the original RIE, factors that changed since the event, and additional process improvements made two years post-RIE

La Escala Mística de Santa Rosa de Lima desde la visión del libro de "Las Moradas" de Santa Teresa de Ávila

Trabajo para optar el Grado de Bachiller en TeologíaEl presente trabajo se pretende hacer un análisis de la Escala mística de Santa Rosa de Lima desde la visión de las Moradas de Santa Teresa de Ávila. Para que a la luz de todo este camino espiritual podamos descubrir y conocer la profundidad de la vida espiritual de nuestra Santa peruana Rosa de Santa María. Claro está que la tarea no es sencilla y mucho menos con los pocos textos escritos que se tienen de la Santa limeña, pero precisamente este es el reto y la riqueza de este proyecto; Que tras haber celebrado los cuatrocientos años de su muerte el 2017 se busque conocer más y profundizar: Esta Santa peruana es conocida más por la dimensión de su vida penitente, fue ante todo una mujer de Dios, con una vida espiritual de la talla de Santa Teresa de Jesús doctora de la Iglesia. Pero tras este atisbo de luz surgen algunas interrogantes ¿Cómo o en qué sentido se puede conocer la escala mística de Santa Rosa desde las moradas de Santa teresa? ¿Qué es y cómo entender lo que es la escala mística? ¿Cuál es la relación que se halla entre estas dos vivencias espirituales experimentadas por estas santas? Para responder estas preguntas y otras que puedan surgir es importante estructurar este trabajo en tres capítulos. En el primero capítulo se habla de la escala mística, cuál es, el significado o connotaciones que tiene; el lenguaje metafórico o alegórico que usa para manifestar la experiencia de lo inefable que se vivencia en el símbolo de la escala mística; así como los dones o mercedes de la escala mística, de manera que se haga una aproximación al grado de su experiencia mística.Trabajo de investigació

Reseñas

Borja Gómez, Jaime Humberto edit. Cogollos Amaya, Silvia. Enciso Patiño, Patricia. Rodríguez Jiménez, Pablo. Sánchez Bohorquez, José Enrique. Esplendiani, Anna María. Vargas Poo, Martín Eduardo. Inquisición, muerte y sexualidad en la Nueva Granada. Santafé de Bogotá: Ariel-CEJA, Colección Ariel-Historia, 1996. 390 pp.Blanco Barros, José Agustín. Tubará. La encomienda mayor de Tierradentro. Santafé de Bogotá: Centro Editorial Javeriano CEJA, 1995. 370 pp

Producing viruses in orbit: Current developments for orbital shaken viral vaccine manufacturing

Preculture of suspension cells is successfully performed in shake flasks. Especially newly developed designer cells are passaged up to 100 times in shake flaks at high shaking frequency and are then perfectly adapted to growth in a CO2 incubator with pH control and maximum oxygen supply (typically above 80% pO2). When they are subsequently transferred to stirred tank bioreactors for scaling up, specific cell growth rates are often lower and cells become sensitive to pH control via acid/base addition and shear stress due to submers gassing (bubbles). This was also seen for avian AGE1.CR.pIX and human HEK 293 cells. To avoid these problems, scale up in shaken mode was evaluated. Here we present the latest developments of the SB10-X OSB bioreactor with regard to bag design and improvement of the control unit. A new control strategy was introduced leading to a faster and more precise pH and DO control. Furthermore, the perfusion bag was optimized, so that on TFF or two ATF systems can be easily connected. Both developments have led to a more robust SB10-X system that allows to easily perform batch, fed batch or perfusion runs. Please click Download on the upper right corner to see the full abstract

A Comparison of Lymphoid and Myeloid Cells Derived from Human Hematopoietic Stem Cells Xenografted into NOD-Derived Mouse Strains

Humanized mice are an invaluable tool for investigating human diseases such as cancer, infectious diseases, and graft-versus-host disease (GvHD). However, it is crucial to understand the strengths and limitations of humanized mice and select the most appropriate model. In this study, we describe the development of the human lymphoid and myeloid lineages using a flow cytometric analysis in four humanized mouse models derived from NOD mice xenotransplanted with CD34+ fetal cord blood from a single donor. Our results showed that all murine strains sustained human immune cells within a proinflammatory environment induced by GvHD. However, the Hu-SGM3 model consistently generated higher numbers of human T cells, monocytes, dendritic cells, mast cells, and megakaryocytes, and a low number of circulating platelets showing an activated profile when compared with the other murine strains. The hu-NOG-EXL model had a similar cell development profile but a higher number of circulating platelets with an inactivated state, and the hu-NSG and hu-NCG developed low frequencies of immune cells compared with the other models. Interestingly, only the hu-SGM3 and hu-EXL models developed mast cells. In conclusion, our findings highlight the importance of selecting the appropriate humanized mouse model for specific research questions, considering the strengths and limitations of each model and the immune cell populations of interest. © 2023 by the authors

Solar Disinfection of MODS Mycobacterial Cultures in Resource-Poor Settings

INTRODUCTION: Safe disposal of TB culture material in which the infectious burden of clinical samples has been greatly amplified is an important challenge in resource-limited settings. The bactericidal capacity of solar cookers has been demonstrated previously for conventional bacteria and contaminated clinical waste. We investigated the use of a simple solar cooker for the sterilization of mycobacterial broth cultures from the microscopic observation drug susceptibility assay (MODS). METHODS: Simulated TB culture materials were prepared by inoculating 24-well MODS plates with 500 microL of a known concentration of Mycobacterium bovis BCG. In a series of experiments, samples were simultaneously placed inside a box-type solar cooker and control box and removed at timepoints between 15 minutes and 6 hours. Quantitative cultures were performed using retrieved samples to determine sterilization effect. RESULTS: All cultures from the control box were positive at or within 1-4 logs of inoculation concentration. Simulated culture plates at concentrations from 10(3) colony-forming-units (CFU)/ml to 10(7) CFU/ml were completely sterilized after only one hour of cooker exposure, at temperatures between 50-102 degrees C. At 10(9) CFU/ml (far in excess of diagnostic cultures), it was only possible to recover mycobacterial growth in plates removed after 15 minutes. By 30 minutes all plates were effectively sterilized. DISCUSSION: Solar disinfection provides a very effective, safe and low-cost alternative to conventional equipment used for disposal of mycobacterial culture material. Effect of climatic conditions and optimal operating procedure remain to be defined

Validation of microscopic observation drug susceptibility testing for rapid, direct rifampicin and isoniazid drug susceptibility testing in patients receiving tuberculosis treatment.

Drug susceptibility testing (DST) is often needed in patients clinically failing tuberculosis (TB) therapy. Most studies of phenotypic direct drug susceptibility tests, such as microscopic observation drug susceptibility (MODS) tests, have been performed in patients not receiving TB treatment. The effect of ongoing TB treatment on the performance of MODS direct DST has not been previously explored, but patients failing such therapy constitute an important target group. The aim of this study was to determine the performance of MODS direct rifampicin and isoniazid DST in patients clinically failing first-line TB treatment, and to compare MODS direct DST with indirect proportion method DST. Sputa from 264 TB patients were cultured in parallel in Lowenstein-Jensen (LJ) and MODS assays; strains were tested for rifampicin and isoniazid susceptibility by the proportion method at the national reference laboratory. Ninety-three samples were culture-positive by LJ and MODS (concordance of 96%; kappa 0.92). With conventional MODS plate DST reading (performed on the same day as the sample is classified as culture-positive), the isoniazid DST concordance was 96.8% (kappa 0.89), and the concordance for rifampicin susceptibility testing was 92.6% (kappa 0.80). Reading of MODS DST plates 1 week after cultures had been determined to be culture-positive improved overall performance marginally-the isoniazid DST concordance was 95.7% (kappa 0.85); and the rifampicin DST concordance was 96.8% (kappa 0.91). Sensitivity for detection of multidrug-resistant TB was 95.8%. MODS testing provided reliable rifampicin and isoniazid DST results for samples obtained from patients receiving TB therapy. A modified DST reading schedule for such samples, with a final reading 1 week after a MODS culture turns positive, marginally improves the concordance with reference DST

Rationing tests for drug-resistant tuberculosis - who are we prepared to miss?

BACKGROUND: Early identification of patients with drug-resistant tuberculosis (DR-TB) increases the likelihood of treatment success and interrupts transmission. Resource-constrained settings use risk profiling to ration the use of drug susceptibility testing (DST). Nevertheless, no studies have yet quantified how many patients with DR-TB this strategy will miss. METHODS: A total of 1,545 subjects, who presented to Lima health centres with possible TB symptoms, completed a clinic-epidemiological questionnaire and provided sputum samples for TB culture and DST. The proportion of drug resistance in this population was calculated and the data was analysed to demonstrate the effect of rationing tests to patients with multidrug-resistant TB (MDR-TB) risk factors on the number of tests needed and corresponding proportion of missed patients with DR-TB. RESULTS: Overall, 147/1,545 (9.5%) subjects had culture-positive TB, of which 32 (21.8%) had DR-TB (MDR, 13.6%; isoniazid mono-resistant, 7.5%; rifampicin mono-resistant, 0.7%). A total of 553 subjects (35.8%) reported one or more MDR-TB risk factors; of these, 506 (91.5%; 95% CI, 88.9-93.7%) did not have TB, 32/553 (5.8%; 95% CI, 3.4-8.1%) had drug-susceptible TB, and only 15/553 (2.7%; 95% CI, 1.5-4.4%) had DR-TB. Rationing DST to those with an MDR-TB risk factor would have missed more than half of the DR-TB population (17/32, 53.2%; 95% CI, 34.7-70.9). CONCLUSIONS: Rationing DST based on known MDR-TB risk factors misses an unacceptable proportion of patients with drug-resistance in settings with ongoing DR-TB transmission. Investment in diagnostic services to allow universal DST for people with presumptive TB should be a high priority