An optimized queue management system to improve patient flow in the absence of appointment system.

PURPOSE: The aim of this research study is to develop a queue assessment model to evaluate the inflow of walk-in outpatients in a busy public hospital of an emerging economy, in the absence of appointment systems, and construct a dynamic framework dedicated towards the practical implementation of the proposed model, for continuous monitoring of the queue system. DESIGN/METHODOLOGY/APPROACH: The current study utilizes data envelopment analysis (DEA) to develop a combined queuing-DEA model as applied to evaluate the wait times of patients, within different stages of the outpatients' department at the Combined Military Hospital (CMH) in Lahore, Pakistan, over a period of seven weeks (23rd April to 28th May 2014). The number of doctors/personnel and consultation time were considered as outputs, where consultation time was the non-discretionary output. The two inputs were wait time and length of queue. Additionally, VBA programming in Excel has been utilized to develop the dynamic framework for continuous queue monitoring. FINDINGS: The inadequate availability of personnel was observed as the critical issue for long wait times, along with overcrowding and variable arrival pattern of walk-in patients. The DEA model displayed the "required" number of personnel, corresponding to different wait times, indicating queue build-up. ORIGINALITY/VALUE: The current study develops a queue evaluation model for a busy outpatients' department in a public hospital, where "all" patients are walk-in and no appointment systems. This model provides vital information in the form of "required" number of personnel which allows the administrators to control the queue pre-emptively minimizing wait times, with optimal yet dynamic staff allocation. Additionally, the dynamic framework specifically targets practical implementation in resource-poor public hospitals of emerging economies for continuous queue monitoring.

Changes in mechanical dyssynchrony in severe aortic stenosis patients undergoing transcatheter aortic valve replacement.

INTRODUCTION: Aortic stenosis (AS) imposes a significant afterload on the left ventricle, but regional manifestations of the overall load may not be uniform, leading to mechanical dyssynchrony. Accordingly, we evaluated the prevalence of dyssynchrony in patients with severe AS at baseline as well as changes after transfemoral aortic valve replacement (TAVR). METHODS: This study is a retrospective analysis of 225 patients in sinus rhythm who underwent TAVR for severe AS, in whom inter-ventricular and intra-ventricular dyssynchrony were measured at baseline, discharge, 1 month, and 1 year. Inter-ventricular dyssynchrony was defined as the difference between left and right ventricular pre-ejection intervals; intra-ventricular dyssynchrony was defined as the difference between time to peak systolic velocity of the basal septal and lateral segments. Patients were further stratified into those with QRS <120 ms or >120 ms. RESULTS: At baseline, a quarter of patients met the criterion for significant inter-ventricular dyssynchrony, and a third had evidence of intra-ventricular dyssynchrony. Both decreased after TAVR although only the intra-ventricular dyssynchrony reached statistical significance. The interplay between QRS duration and changes in inter- and intra-ventricular dyssynchrony are also explored. CONCLUSIONS: In patients with severe AS, there was evidence of mechanical dyssynchrony that is improved post-TAVR. Whether dyssynchrony is clinically and prognostically significant, and if it represents a potential target for additional therapy remains to be studied.

Assessing the Queuing Process Using Data Envelopment Analysis: an Application in Health Centres.

Queuing is one of the very important criteria for assessing the performance and efficiency of any service industry, including healthcare. Data Envelopment Analysis (DEA) is one of the most widely-used techniques for performance measurement in healthcare. However, no queue management application has been reported in the health-related DEA literature. Most of the studies regarding patient flow systems had the objective of improving an already existing Appointment System. The current study presents a novel application of DEA for assessing the queuing process at an Outpatients' department of a large public hospital in a developing country where appointment systems do not exist. The main aim of the current study is to demonstrate the usefulness of DEA modelling in the evaluation of a queue system. The patient flow pathway considered for this study consists of two stages; consultation with a doctor and pharmacy. The DEA results indicated that waiting times and other related queuing variables included need considerable minimisation at both stages.

Clerkship Grading and the U.S. Economy: What Medical Education Can Learn From America's Economic History.

Clerkship grades (like money) are a social construct that function as the currency through which value exchanges in medical education are negotiated between the system's various stakeholders. They provide a widely recognizable and efficient medium through which learner development can be assessed, tracked, compared, and demonstrated and are commonly used to make decisions regarding progression, distinction, and selection for residency. However, substantial literature has demonstrated how grades imprecisely and unreliably reflect the value of learners. In this article, the authors suggest that challenges with clerkship grades are fundamentally tied to their role as currency in the medical education system. Associations are drawn between clerkship grades and the history of the U.S. economy; 2 major concepts are highlighted: regulation and stock prices. The authors describe the history of these economic concepts and how they relate to challenges in clerkship grading. Using lessons learned from the history of the U.S. economy, the authors then propose a 2-step solution to improve upon grading for future generations of medical students: (1) transition from grades to a federally regulated competency-based assessment model and (2) development of a departmental competency letter that incorporates competency-based assessments rather than letter grades and meets the needs of program directors.

Onco-hypertension: An Emerging Specialty.

Cancer is one of the leading causes of death worldwide. With the introduction of newer chemotherapeutic agents, targeted therapies, and immunotherapy, the prognosis and survival of patients with cancer has remarkably improved. As a result, patients are living longer and experiencing long-term cardiovascular complications. Hypertension is an important risk factor for cardiovascular diseases. Patients with malignancy have multiple etiologies of hypertension development, worsening, or association. This is because of the complex interplay between cancer type, chemotherapeutic agent, patient age, antihypertensive agent, and preexisting comorbidities in the etiology and pathogenesis of hypertension. Management of hypertension in patients with cancer requires accurate blood pressure measurement and considering factors such as adjuvant therapy and cancer-related pain. There are no set guidelines for management of hypertension in this unique cohort, and the therapy should be individualized based on the treatment guidelines for the general population. Onco-hypertension is an emerging subspeciality and entails a multidisciplinary approach between oncology, primary care physicians, nephrology, and cardiology.

The One Note System: Implementation and Initial Perceptions of Student Documentation in the Electronic Health Records Under the New Centers for Medicare and Medicaid Services Guidelines.

Introduction Medical students have been documenting notes in the electronic health records (EHR) for many years but often wrote separate notes from housestaff and faculty because licensed providers (LPs) could not bill the Centers for Medicare and Medicaid Services (CMS) for Evaluation and Management (E/M) services. However, in 2018, CMS updated its policy to allow LPs to simply verify any component of an E/M service under appropriate supervision, allowing LPs to bill a full medical student note. Methods At Virginia Commonwealth University Health Systems (VCUHS), a task force was formed to develop and pilot the One Note System (ONS), a system that incorporates the new CMS guidelines for certain note types. In June 2019, or 10 months after implementation of the ONS, the authors developed and distributed a survey that explored perceptions regarding the ONS among medical students, housestaff (residents and fellows), and faculty. Results The results showed that most participants were aware of the ONS and preferred email as the form of training. Overall, the ONS had a positive impact on faculty and housestaff workflow, improved self-reported faculty wellbeing, and increased meaning in student work. Only a minority reported barriers to implementing the ONS. Conclusions The One Note System was successfully implemented at VCUHS and positively received. Other outcomes to measure include impact of the ONS on student and trainee education, compliance and billing, quality and quantity of documentation, and faculty and housestaff burnout rates.

Cardiac magnetic resonance tissue tracking in right ventricle: Feasibility and normal values.

PURPOSE: To investigate right ventricular (RV) strain in patients without identified cardiac pathology using cardiac magnetic resonance tissue tracking (CMR TT). METHODS: A total of 50 consecutive patients with no identified cardiac pathology were analyzed. RV longitudinal and circumferential strain was assessed by CMR TT. The age range was 4-81years with a median of 32years (interquartile range, 15 to 56years). RESULTS: Analysis time per patient was <5min. The peak longitudinal strain (Ell) was -22.11±3.51%. The peak circumferential strains (Ecc) for global, basal, mid-cavity and apical segments were as follows: -11.69±2.25%, -11.00±2.45%, -11.17±3.36%, -12.90±3.34%. There were significant gender differences in peak Ecc at the base (P=0.04) and the mid-cavity (P=0.03) with greater deformation in females than in males. On Bland-Altman analysis, peak Ell (mean bias, 0.22±1.67; 95% CI -3.05 to 3.49) and mid-cavity Ecc (mean bias, 0.036±1.75; 95% CI, -3.39 to 3.47) had the best intra-observer agreement and inter-observer agreement, respectively. CONCLUSIONS: RV longitudinal and circumferential strains can be quickly assessed with good intra-observer and inter-observer variability using TT.

UBR-5, a Conserved HECT-Type E3 Ubiquitin Ligase, Negatively Regulates Notch-Type Signaling in Caenorhabditis elegans.

Notch-type signaling mediates cell-cell interactions important for animal development. In humans, reduced or inappropriate Notch signaling activity is associated with various developmental defects and disease states, including cancers. Caenorhabditis elegans expresses two Notch-type receptors, GLP-1 and LIN-12. GLP-1 mediates several cell-signaling events in the embryo and promotes germline proliferation in the developing and adult gonad. LIN-12 acts redundantly with GLP-1 in certain inductive events in the embryo and mediates several cell-cell interactions during larval development. Recovery of genetic suppressors and enhancers of glp-1 or lin-12 loss- or gain-of-function mutations has identified numerous regulators of GLP-1 and LIN-12 signaling activity. Here, we report the molecular identification of sog-1, a gene identified in screens for recessive suppressors of conditional glp-1 loss-of-function mutations. The sog-1 gene encodes UBR-5, the sole C. elegans member of the UBR5/Hyd family of HECT-type E3 ubiquitin ligases. Molecular and genetic analyses indicate that the loss of ubr-5 function suppresses defects caused by reduced signaling via GLP-1 or LIN-12. In contrast, ubr-5 mutations do not suppress embryonic or larval lethality associated with mutations in a downstream transcription factor, LAG-1. In the gonad, ubr-5 acts in the receiving cells (germ cells) to limit GLP-1 signaling activity. SEL-10 is the F-box component of SCF(SEL-10) E3 ubiquitin-ligase complex that promotes turnover of Notch intracellular domain. UBR-5 acts redundantly with SEL-10 to limit Notch signaling in certain tissues. We hypothesize that UBR-5 activity limits Notch-type signaling by promoting turnover of receptor or limiting its interaction with pathway components.