Improving Compliance with the CMS SEP-1 Sepsis Bundle at a Community-Based Teaching Hospital Emergency Department.

INTRODUCTION: The Centers for Medicare & Medicaid Services (CMS) designed Hospital Quality Initiatives (HQI) to assure delivery of quality health care for institutions receiving Medicare payments. Like many teaching institutions, the SEP-1 compliance rates at McLaren Oakland in Pontiac fluctuated monthly and were not achieving institutional target expectations. METHODS: The project team designed a Sepsis Macro and a Sepsis Order Set in the electronic medical record system. The project team also implemented an educational initiative targeted at emergency medicine resident and attending physicians. The educational initiative instructed emergency medicine resident and attending physicians in the metrics measured in the SEP-1 bundle as well as how to properly use the newly designed Sepsis Macro and Sepsis Order Set. RESULTS: After implementation of the Sepsis Macro and Sepsis Order Set, the overall compliance with the SEP-1 bundle improved from 57% to 62%, above national averages and at the institutional target expectations. However, there were not statistically significant differences (p = 0.562) between the compliance rate before and after program implementation (Pre = 57% (SD = 0.27); 95% CI: 0.29 - 0.85); Post= 62% (SD = 0.11); 95% CI: 0.55 - 0.70). After program implementation the SEP-1 compliance rate was met in 82% of the months in comparison with 50% of the months in the pre-intervention (p = 0.28). CONCLUSIONS: Although not achieving statistical significance, this intervention demonstrated that simple, cost-effective measures of education and standardization in documentation and order entry in EMR's can improve clinically significant compliance to CMS HQI metrics in community-based teaching institutions.

Direct Pathway Cloning (DiPaC) to unlock natural product biosynthetic potential.

Specialized metabolites from bacteria are an important source of inspiration for drug development. The genes required for the biosynthesis of such metabolites in bacteria are usually organized in so-called biosynthetic gene clusters (BGCs). Using modern bioinformatic tools, the wealth of genomic data can be scanned for such BGCs and the expected products can often structurally be predicted in silico. This facilitates the directed discovery of putatively novel bacterial metabolites. However, the production of these molecules often requires genetic manipulation of the BGC for activation or the expression of the pathway in a heterologous host. The latter necessitates the transplantation of the BGC into a suitable expression system. To achieve this goal, powerful cloning strategies based on in vivo homologous recombination have recently been developed. This includes LCHR and LLHR in E. coli as well as TAR cloning in yeast. Here, we present Direct Pathway Cloning (DiPaC) as an efficient complementary BGC capturing strategy that relies on long-amplicon PCR and in vitro DNA assembly. This straightforward approach facilitates full pathway assembly, BGC refactoring and direct transfer into any vector backbone in vitro. The broad applicability and efficiency of DiPaC is demonstrated by the discovery of a new phenazine from Serratia fonticola, the first heterologous production of anabaenopeptins from Nostoc punctiforme and the transfer of the native erythromycin BGC from Saccharopolyspora erythraea into Streptomyces. Due to its simplicity, we envisage DiPaC to become an essential method for BGC cloning and metabolic pathways construction with significant applications in metabolic engineering, synthetic biology and biotechnology.

South Africa's universal health coverage reforms in the post-apartheid period.

In 2011, the South African government published a Green Paper outlining proposals for a single-payer National Health Insurance arrangement as a means to achieve universal health coverage (UHC), followed by a White Paper in 2015. This follows over two decades of health reform proposals and reforms aimed at deepening UHC. The most recent reform departure aims to address pooling and purchasing weaknesses in the health system by internalising both functions within a single scheme. This contrasts with the post-apartheid period from 1994 to 2008 where pooling weaknesses were to be addressed using pooling schemes, in the form of government subsidies and risk-equalisation arrangements, external to the public and private purchasers. This article reviews both reform paths and attempts to reconcile what may appear to be very different approaches. The scale of the more recent set of proposals requires a very long reform path because in the mid-term (the next 25 years) no single scheme will be able to raise sufficient revenue to provide a universal package for the entire population. In the interim, reforms that maintain and improve existing forms of coverage are required. The earlier reform framework (1994-2008) largely addressed this concern while leaving open the final form of the system. Both reform approaches are therefore compatible: the earlier reforms addressed medium- to long-term coverage concerns, while the more recent define the long-term institutional goal.