Reducing Wasted Time Prior To Starting Thoracic Surgical Operations.

To design and implement multidisciplinary interventions to decrease the interval between when a patient entered the operating room and when skin incision was made during thoracic surgical operations. Thirty-eight steps that occurred during the pre-incision time were identified during meetings with surgery, anesthesia, and nursing teams. Using a critical path method and Pareto analysis, standardization of intubation and positioning techniques as well as establishing strict guidelines to avoid unnecessary urinary catheter and arterial line placement were identified as high-value interventions. The duration of every step, and the total pre-incision time, was recorded during four phases of this project: (1) a pre-intervention period; (2) a run-in period; (3) a post-intervention period; and (4) a follow-up period five months later. 101 cases were analyzed. The median (IQR) pre-incision time dropped from 42.5(36-61) min prior to intervention to 34.5(29-39.5). This improvement persisted at five months (33 (28-41) min). Median positioning time decreased from 9(7-11) min to 4(3-5) min, with improvement persistent at late analysis 5(3.5-6) min. Median intubation times decreased from 7.5(5-15.5) min to 6(5-8) min post-intervention, with persistent improvement at five months 6(4-8). Engagement of a multidisciplinary team to design interventions to streamline pre-incision steps reduced the pre-incision time by 19%. Persistence of this improvement likely reflects the investment each teams' members had in achieving efficiency. Decreasing variability in the processes helped to achieve these benefits.

Reducing Opioid Mortality in Illinois (ROMI): A case management/peer recovery coaching critical time intervention clinical trial protocol.

Individuals with a history of opioid use are disproportionately represented in Illinois jails and prisons and face high risks of overdose and relapse at community reentry. Case management and peer recovery coaching are established interventions that may be leveraged to improve linkage to substance use treatment and supportive services during these critical periods of transition. We present the protocol for the Reducing Opioid Mortality in Illinois (ROMI), a type I hybrid effectiveness-implementation randomized trial of a case management, peer recovery coaching and overdose education and naloxone distribution (CM/PRC + OEND) critical time intervention (CTI) compared to OEND alone. The CM/PRC + OEND is a novel, 12-month intervention that involves linkage to substance use treatment and support for continuity of care, skills building, and navigation and engagement of social services that will be implemented using a hub-and-spoke model of training and supervision across the study sites. At least 1000 individuals released from jails and prisons spanning urban and rural settings will be enrolled. The primary outcome is engagement in medication for opioid use disorder. Secondary outcomes include health insurance enrollment, mental health service engagement, and re-arrest/recidivism, parole violation, and/or reincarceration. Mixed methods will be used to evaluate process and implementation outcomes including fidelity to, barriers to, facilitators of, and cost of the intervention. Videoconferencing and other remote processes will be leveraged to modify the protocol for safety during the COVID-19 pandemic. Results of the study may improve outcomes for vulnerable persons at the margin of behavioral health and the criminal legal system.

Structural and compositional shifts in Cerrado fragments in up to 11 years monitoring

The Cerrado has a wide diversity of fauna and flora, and the knowledge of its horizontal structure, in different time intervals allows the prediction of its structural and floristic characteristics. The aim of this study was to evaluate the changes in structure and composition of tree community in three fragments of Cerrado with low anthropization, in an interval of 11 years at Minas Gerais state. Rectangular plots of fixed size were sampled, measuring stem diameter and height of all living arboreal individuals with diameter at 1.30 meters above ground (DBH) ≥ 5 cm. The tree vegetation dynamics study of the areas was performed, as well as the floristic analysis and the diametric structure. Considering all fragments and years of measurement, the recruitment of trees surpassed its mortality. The basal area varied between 3.67 and 13.07 m².ha-1. The studied areas, considering all fragments and years of measurement, showed a Shannon diversity index (H') from 3.43 to 3.87 nat.ind-1 and Pielou equitability index (J') ranged an interval between 0.77 and 0.82. The similarity calculated by the Jaccard index (J), when performed per plot considering the three fragments, showed a value of 0.2653. Also, related to the development and growth of the study areas, it can be inferred that all fragments and their respective years of measurement had a J-inverse pattern. In conclusion, it can be inferred that the three fragments maintained a representative growth in number of individuals and basal area.

Collegiate-based emergency medical service: impact on alcohol-related emergency department transports at a small liberal arts college.

OBJECTIVE: The authors examined the impact of a collegiate-based emergency medical service (CBEMS) on the frequency of emergency department (ED) transports. PARTICIPANTS: Students transported to the ED for acute alcohol intoxication during the Fall 2008 and the Fall 2009 semesters (N = 50). METHODS: The frequency of students receiving transportation to a hospital ED and the reported blood alcohol content (BAC) levels during the initial operational semester of the CBEMS were compared to those values over the same time period the previous year. RESULTS: More than twice the number of students was transported to the ED following the introduction of CBEMS. There was no change in mean BAC levels. CONCLUSIONS: CBEMS could promote a culture conducive to increased reporting behavior, which makes the campus safer. Similar BAC levels suggest that the degree of intoxication was similar for the 2 reporting periods, but students sought emergency assistance more frequently following the inception of CBEMS.