Key Players in Key Roles: The Baystate Patient Progress Initiative to Improve Emergency Department Efficiency and Productivity.

BACKGROUND: The percentage of patients who leave the emergency department without being seen by a provider is a measure of efficiency and presents risk-management concerns. The number of patients actually "seen" by a provider is a measure of productivity. The opening of our new emergency department in December 2012, resulted in increases in both demand and the percentage of patients who left without being seen. Operational nursing leadership managed ED patient flow, but the structure was loosely organized on an ad hoc basis. METHODS: Operational nursing leadership roles were re-assigned to personnel with management aptitude and interest. The charge nurse coordinated care throughout all sections (pods) of the department while the pod lead nurse coordinated care in each pod. The flow coordinator nurse accepted transfers and emergency medical services arrivals. Nursing and physician staffing remained unchanged, and measures were calculated over a 3-year period (December 3, 2012, to December 2, 2015). The number of patients seen per day was analyzed using simple linear regression. The percentage of patients who left without being seen was analyzed using fractional logistic regression; P< 0.05 was considered statistically significant. RESULTS: The weekly mean number of patients seen per day rose 13% from 265 to 299 patients. The weekly mean percentage of patients who left without being seen declined 45% from 8.2% to 4.5%. The regression lines for both measures were significant at P < 0.001. CONCLUSION: Measures of efficiency and productivity can be improved significantly with a dedicated operational nursing leadership structure without adding nursing or physician staffing.

Decreasing Emergency Department Walkout Rate and Boarding Hours by Improving Inpatient Length of Stay.

INTRODUCTION: Patient progress, the movement of patients through a hospital system from admission to discharge, is a foundational component of operational effectiveness in healthcare institutions. Optimal patient progress is a key to delivering safe, high-quality and high-value clinical care. The Baystate Patient Progress Initiative (BPPI), a cross-disciplinary, multifaceted quality and process improvement project, was launched on March 1, 2014, with the primary goal of optimizing patient progress for adult patients. METHODS: The BPPI was implemented at our system's tertiary care, academic medical center, a high-volume, high-acuity hospital that serves as a regional referral center for western Massachusetts. The BPPI was structured as a 24-month initiative with an oversight group that ensured collaborative goal alignment and communication of operational teams. It was organized to address critical aspects of a patient's progress through his hospital stay and to create additional inpatient capacity. The specific goal of the BPPI was to decrease length of stay (LOS) on the inpatient adult Hospital Medicine service by optimizing an interdisciplinary plan of care and promoting earlier departure of discharged patients. Concurrently, we measured the effects on emergency department (ED) boarding hours per patient and walkout rates. RESULTS: The BPPI engaged over 300 employed clinicians and non-clinicians in the work. We created increased inpatient capacity by implementing daily interdisciplinary bedside rounds to proactively address patient progress; during the 24 months, this resulted in a sustained rate of discharge orders written before noon of more than 50% and a decrease in inpatient LOS of 0.30 days (coefficient: -0.014, 95% CI [-0.023, -0.005] P< 0.005). Despite the increase in ED patient volumes and severity of illness over the same time period, ED boarding hours per patient decreased by approximately 2.1 hours (coefficient: -0.09; 95% CI [-0.15, -0.02] P = 0.007). Concurrently, ED walkout rates decreased by nearly 32% to a monthly mean of 0.4 patients (coefficient: 0.4; 95% CI [-0.7, -0.1] P= 0.01). CONCLUSION: The BPPI realized significant gains in patient progress for adult patients by promoting earlier discharges before noon and decreasing overall inpatient LOS. Concurrently, ED boarding hours per patient and walkout rates decreased.

Inertio-elastic focusing of bioparticles in microchannels at high throughput.

Controlled manipulation of particles from very large volumes of fluid at high throughput is critical for many biomedical, environmental and industrial applications. One promising approach is to use microfluidic technologies that rely on fluid inertia or elasticity to drive lateral migration of particles to stable equilibrium positions in a microchannel. Here, we report on a hydrodynamic approach that enables deterministic focusing of beads, mammalian cells and anisotropic hydrogel particles in a microchannel at extremely high flow rates. We show that on addition of micromolar concentrations of hyaluronic acid, the resulting fluid viscoelasticity can be used to control the focal position of particles at Reynolds numbers up to Re≈10,000 with corresponding flow rates and particle velocities up to 50 ml min(-1) and 130 m s(-1). This study explores a previously unattained regime of inertio-elastic fluid flow and demonstrates bioparticle focusing at flow rates that are the highest yet achieved.

Necator americanus and helminth co-infections: further down-modulation of hookworm-specific type 1 immune responses.

BACKGROUND: Helminth co-infection in humans is common in tropical regions of the world where transmission of soil-transmitted helminths such as Ascaris lumbricoides, Trichuris trichiura, and the hookworms Necator americanus and Ancylostoma duodenale as well as other helminths such as Schistosoma mansoni often occur simultaneously. METHODOLOGY: We investigated whether co-infection with another helminth(s) altered the human immune response to crude antigen extracts from either different stages of N. americanus infection (infective third stage or adult) or different crude antigen extract preparations (adult somatic and adult excretory/secretory). Using these antigens, we compared the cellular and humoral immune responses of individuals mono-infected with hookworm (N. americanus) and individuals co-infected with hookworm and other helminth infections, namely co-infection with either A. lumbricoides, Schistosoma mansoni, or both. Immunological variables were compared between hookworm infection group (mono- versus co-infected) by bootstrap, and principal component analysis (PCA) was used as a data reduction method. CONCLUSIONS: Contrary to several animal studies of helminth co-infection, we found that co-infected individuals had a further downmodulated Th1 cytokine response (e.g., reduced INF-γ), accompanied by a significant increase in the hookworm-specific humoral immune response (e.g. higher levels of IgE or IgG4 to crude antigen extracts) compared with mono- infected individuals. Neither of these changes was associated with a reduction of hookworm infection intensity in helminth co-infected individuals. From the standpoint of hookworm vaccine development, these results are relevant; i.e., the specific immune response to hookworm vaccine antigens might be altered by infection with another helminth.