Bursting at the Seams: Improving Patient Flow to Help America\u27s Emergency Departments

From 1992 to 2002, the number of annual ED visits increased 23 percent in the U.S., while the number of EDs decreased by 15 percent. Many EDs are overwhelmed by the number of patients needing their services, with 62 percent of the nation\u27s EDs reporting being at or over operating capacity. Almost daily, newspaper headlines across the country relay stories about patients waiting for hours in the ED before being seen and tales of ambulances being diverted from one hospital to the next due to overcrowding. But while much of the blame for this situation has been placed on broader social issues—such as increasing numbers of uninsured Americans and increasing reliance on the ED by those who are insured—many hospitals have done little to address the patient flow obstacles that lead to overcrowded EDs. The Urgent Matters program, a national initiative of The Robert Wood Johnson Foundation, has worked intensely to try to find solutions to this problem that may be applicable nationwide. Urgent Matters has a commitment to develop and spread patient flow best practices to America\u27s hospitals

Perfecting Patient Flow: America\u27s Safety Net Hospitals and Emergency Department Crowding

Emergency department crowding and delays have become major issues for America\u27s safety net hospitals and health systems. Many facilities are experiencing increasing wait times, a need to board admitted patients in emergency department (ED) hallways, and rising numbers of hours spent on diversion or bypass. These trends result from increased patient demand at a time when the number of emergency departments has declined and hospital inpatient capacity has lagged. Other factors also may contribute to the crisis. Patients without access to medical specialists may view the ED as the quickest route to specialized services. Overburdened physicians may be more likely to refer patients to an ED for care, especially if they view the ED as a comprehensive diagnostic center. Meanwhile, shortages of nurses and on-call specialists may slow the care of patients once they get to the ED. Given these complex factors, solutions we once thought would relieve ED demand, like expanded primary care capacity, may actually do little to alleviate this crisis. For patients as well as caregivers, these are more than issues of convenience. Many of the patients who, due to their frustration at the long wait, leave a hospital ED without being seen by a physician do indeed need immediate medical care. Overworked health professionals are more prone to error, and a crowded ED is more likely to experience high turnover and vacancy rates. Long delays and overextended staffing are recipes for low quality, medical error, and poor morale. Faced with the unique mandate of the Emergency Medical Treatment and Labor Act of 1986 (EMTALA), as well as with historic missions to care for all, safety net hospitals may be especially strained by these conditions. These hospitals often run large emergency departments with trauma and other specialized services and treat many medically and socially complex patients in an environment of declining or no payment. Yet they are expected to care for all comers, and to do it well while being accountable to the public. The National Association of Public Hospitals and Health Systems (NAPH) commissioned this report, Perfecting Patient Flow: America\u27s Safety Net Hospitals and Emergency Department Crowding, to describe practical approaches to reducing ED crowding as implemented in three member hospitals. Each of these hospitals participated in the year-long Robert Wood Johnson Foundation-funded safety net collaborative, Urgent Matters. These three hospitals, The Regional Medical Center at Memphis, Boston Medical Center, and Grady Health System in Atlanta, were chosen through a highly selective process to participate in the project, which was headquartered at The George Washington University Medical Center School of Public Health and Health Services

Walking a Tightrope: The State of the Safety Net in Ten U.S. Communities

This report presents the findings from the Urgent Matters safety net assessments and identifies common characteristics, opportunities and challenges for communities that wish to better serve the health care needs of uninsured and underserved individuals. It also illustrates differences across many of the communities, especially in terms of the structure and financing of their safety nets. It is a companion report to the individual safety net assessments and provides an overarching perspective of problems that affect safety nets across the country

Assumed equity: Early observations from the first Hospital Disparities Collaborative

Disparities in healthcare represent a failure in the equity domain of quality. Although disparities have been well documented, little has been written about how hospitals might use improved data collection and quality improvement techniques to eliminate disparities. This article describes early findings from the planning phase of the first hospital-based disparities collaborative. The authors also discuss the changes in policy and practice that may speed hospitals in placing disparities and equity on their quality agendas

Levels and patterns of physical activity and sedentary time among superdiverse adolescents in East London: a cross-sectional study

Objectives: Little is known about the physical activity (PA) and sedentary time (ST) habits of adolescents from superdiverse communities in the UK. The objectives of this study are to examine and report the patterns of PA/ST among adolescents in East London living in superdiverse communities, to identify opportunities/barriers to PA and inform policy/practice. Design: 1,260 young people (aged 11-13) young people from 7 secondary schools in East London completed a questionnaire on PA/ST over the past 7 days as part of the Newham's Every Child a Sports Person (NECaSP) intervention. Socio-demographic and anthropometric data were obtained. Significance tests were conducted to determine differences between socio-demographic and anthropometric predictors and PA/ST. Multinomial logit regression was used to explore the effects of ethnicity, sex and BMI on PA levels. Results: Males were significantly more likely to engage in PA at least 5 times during school in the past week (U=5.07, z= -11.76, p< .05). Obese participants were less likely to report engaging in PA 5 times in the past week (U=4.11, z= -1.17, p< .05). Black Caribbean girls (U=5.08, z= -1.92, p< .05) were significantly more likely to report engaging in no activity. Multinomial logit regression analyses revealed that girls with higher BMI were less likely to engage in PA at least 4 times after school in the last week than boys (b=.11, Wald X2(1)=9.81, p< .01). Walking (36.4%), jogging/running (29.9%), and football (28%) were the most frequently reported activities. Conclusion: Engaging girls in PA during and after school is important and making sports clubs and activities available and attractive to this target group may help increase engagement in PA and reduce ST. Findings support the need for more sex-specific and culturally responsive pedagogy in schools with curricula that respects diversity and individuality and has meaning and value amongst superdiverse young people. Finally, we need to extend current work presented and provide substantial evidence of the ways young people from minority ethnic groups process and act on the public health policy and the ways they understand and enact physical activity

An evaluation of Bradfordizing effects

The purpose of this paper is to apply and evaluate the bibliometric method Bradfordizing for information retrieval (IR) experiments. Bradfordizing is used for generating core document sets for subject-specific questions and to reorder result sets from distributed searches. The method will be applied and tested in a controlled scenario of scientific literature databases from social and political sciences, economics, psychology and medical science (SOLIS, SoLit, USB Köln Opac, CSA Sociological Abstracts, World Affairs Online, Psyndex and Medline) and 164 standardized topics. An evaluation of the method and its effects is carried out in two laboratory-based information retrieval experiments (CLEF and KoMoHe) using a controlled document corpus and human relevance assessments. The results show that Bradfordizing is a very robust method for re-ranking the main document types (journal articles and monographs) in today’s digital libraries (DL). The IR tests show that relevance distributions after re-ranking improve at a significant level if articles in the core are compared with articles in the succeeding zones. The items in the core are significantly more often assessed as relevant, than items in zone 2 (z2) or zone 3 (z3). The improvements between the zones are statistically significant based on the Wilcoxon signed-rank test and the paired T-Test

Sensitization to inhalant and food allergens in Brazilian atopic children by in vitro total and specific IgE assay: Allergy Project - PROAL

OBJECTIVE: To determine the frequency of sensitization to inhalant and food allergens in children seen at Brazilian allergy services. PATIENTS AND METHODS: Total and specific IgE serum levels to inhalant and food allergens (RAST, UniCAP® - Pharmacia) were measured in 457 children accompanied in pediatric allergy services and in 62 control children age matched. RAST equal or higher than class 1 was considered as positive (R+). RESULTS: Frequency of R+ was significantly higher among atopics (361/457, 79%) when compared to controls (16/62, 25.8%). There were no differences according to gender. The frequency of R+ to all allergens evaluated were higher among atopics when compared to controls. Significantly higher total IgE serum levels were observed among the atopics with R+ in comparison to those with R-. The frequency of R+ to main inhalant allergens were: D. pteronyssinus = 66.7% x 14.5% (p < 0.05), D. farinae = 64.5% x 17.8% (p < 0.05), B. tropicalis = 55.2% x 19.4% (p < 0.05), cockroach = 32.8% x 9.7% (p < 0.05), and cat = 12% x 8.1%. In relation to food allergens we observed: fish = 29.5% x 11.3% (p < 0.05), egg = 24.4% x 4.8% (p < 0.05), cow's milk = 23.1% x 3.2% (p < 0.05), wheat = 20% x 8.1% (p < 0.05), peanuts = 14% x 4.8% (p < 0.05), soy = 11.8% x 4.8% (p < 0.05), and corn = 10.6% x 4.8% (p < 0.05). With respect of age, food allergen sensitization predominates in young children whereas the inverse occurs with inhalant allergens. CONCLUSIONS: There was a predominant frequency of sensitization to inhalant allergens, mainly house dust mites in the evaluated patients. Food allergens were also responsible for a significant proportion of sensitization, mainly in infants.OBJETIVO: Determinar a freqüência de sensibilização a alérgenos inalantes e alimentares em crianças atendidas em serviços brasileiros de alergia. PACIENTES E MÉTODOS: IgE sérica total e específica (RAST) a alérgenos inalantes e alimentares (UniCAP® - Pharmacia) foram determinados em 457 crianças acompanhadas em serviços de alergia pediátrica e em um grupo de controles (n = 62). Resultados classe igual ou maior que 1 foram considerados positivos (R+). RESULTADOS: A freqüência de R+ foi significantemente maior entre os atópicos (361/457, 79%) quando comparados aos controles (16/62, 25,8%). Não houve diferenças quanto ao sexo. A prevalência de R+ entre os atópicos foi significantemente maior para todos os alérgenos avaliados. Os níveis séricos de IgE total foram significantemente mais elevados entre os atópicos com R+ quando comparados aos com R-. Comparando-se atópicos e controles, a freqüência de R+ para os principais alérgenos inalantes foi como segue: D. pteronyssinus = 66,7 versus 14,5% (p < 0,05), D. farinae = 64,5 versus 17,8% (p < 0,05), B. tropicalis = 55,2 versus 19,4% (p < 0,05), barata = 32,8 versus 9,7% (p < 0,05) e gato = 12 versus 8,1%. Com os alimentos, observou-se: peixe = 29,5 versus 11,3% (p < 0,05), ovo = 24,4 versus 4,8% (p < 0,05), leite de vaca = 23,1 versus 3,2% (p < 0,05), trigo = 20 versus 8,1% (p < 0,05), amendoim = 14 versus 4,8% (p < 0,05), soja = 11,8 versus 4,8% (p < 0,05) e milho = 10,6 versus 4,8% (p < 0,05). Segundo a idade, os R+ aos alimentares predominaram entre as crianças mais jovens, e o inverso ocorreu com os inalantes. CONCLUSÕES: Nesta população, predominou a sensibilização aos aeroalérgenos, sobretudo aos ácaros domiciliares, e os alimentos foram importantes em crianças mais jovens.Universidade Federal de São Paulo (UNIFESP) Departamento de Pediatria Disciplina de Alergia e Imunologia Clínica e ReumatologiaUniversidade Federal de São Paulo (UNIFESP)Grupo PROALUNIFESP, Depto. de Pediatria Disciplina de Alergia e Imunologia Clínica e ReumatologiaUNIFESPSciEL

JWST/NIRCam coronagraph: mask design and fabrication

The NIRCam instrument on the James Webb Space Telescope will provide coronagraphic imaging from λ =1-5 μm of high contrast sources such as extrasolar planets and circumstellar disks. A Lyot coronagraph with a variety of circular and wedge-shaped occulting masks and matching Lyot pupil stops will be implemented. The occulters approximate grayscale transmission profiles using halftone binary patterns comprising wavelength-sized metal dots on anti-reflection coated sapphire substrates. The mask patterns are being created in the Micro Devices Laboratory at the Jet Propulsion Laboratory using electron beam lithography. Samples of these occulters have been successfully evaluated in a coronagraphic testbed. In a separate process, the complex apertures that form the Lyot stops will be deposited onto optical wedges. The NIRCam coronagraph flight components are expected to be completed this year

A high-resolution map of human evolutionary constraint using 29 mammals.

The comparison of related genomes has emerged as a powerful lens for genome interpretation. Here we report the sequencing and comparative analysis of 29 eutherian genomes. We confirm that at least 5.5% of the human genome has undergone purifying selection, and locate constrained elements covering ∼4.2% of the genome. We use evolutionary signatures and comparisons with experimental data sets to suggest candidate functions for ∼60% of constrained bases. These elements reveal a small number of new coding exons, candidate stop codon readthrough events and over 10,000 regions of overlapping synonymous constraint within protein-coding exons. We find 220 candidate RNA structural families, and nearly a million elements overlapping potential promoter, enhancer and insulator regions. We report specific amino acid residues that have undergone positive selection, 280,000 non-coding elements exapted from mobile elements and more than 1,000 primate- and human-accelerated elements. Overlap with disease-associated variants indicates that our findings will be relevant for studies of human biology, health and disease