Development and Evolution of a Statewide Outpatient Consultation Service: Leveraging Telemedicine to Improve Access to Specialty Care.

Despite a robust health care system in the United States, many Americans experience health care disparities as a result of poor access to medical care. Academic medicine plays an important role in addressing health care disparities by providing primary and specialty care for the poor and uninsured. In South Carolina, 43 of its 46 counties are designated as fully or partially Medically Underserved Areas (MUAs), defined as areas with a shortage of medical providers, high infant mortality, and either high elderly population or high poverty rates. To address these health care disparities, an academic medical center in South Carolina created a hub-and-spoke specialty care model using telemedicine in partnership with primary care providers across community settings. Initial private foundation grant funding enabled the development and dissemination of technology to provide remote teleconsultations by physicians at the academic medical center (hub) to patients in their primary care offices (spoke). This model, now supported by recurring state funding and professional billing, provides much-needed services, including psychiatry, nutrition counseling, and various surgical and medical subspecialties, to rural and underserved populations in the state. This manuscript provides a narrative review of the development of this statewide telemedicine service, with an emphasis on identification of stakeholders, technology issues, barriers to implementation, and future directions.

Use of non-partitioned ventilator tubing results in dead-space ventilation hypercarbia.

We present a case of severe postoperative hypercarbia in a patient with severe COPD. Hypercarbia and respiratory acidosis continued to increase despite maximal ventilation, bronchodilator therapy, sedation, and paralysis. Mistaken use of non-partitioned ventilator circuit was the cause of the hypercarbia. The ventilator's self-test function failed to detect the error. We changed to a partitioned-lumen circuit, with much less ventilation dead space, and the hypercarbia resolved immediately.

Team-building and change management in respiratory care: description of a process and outcomes.

BACKGROUND: Teamwork promotes enhanced outcomes in various business sectors but can be hampered when there are organizational "silos." This study describes an intervention that fostered teamwork among 4 separate respiratory therapy (RT) departments within a single hospital. METHODS: An initial retreat of leaders of the 4 RT groups indicated a common goal of developing a scorecard by which RT outcomes could be followed and improved. Developing this scorecard involved a business review process that comprised 7 facilitated meetings, in which the 4 RT groups developed metrics and targets for RT outcomes in 4 categories: quality/innovation; service; productivity; and employee engagement. RESULTS: The process of developing the scorecard prompted improvements in the quality of RT care (eg, enhanced cross-staffing, low respiratory therapist turnover). A welcome impact of the business review process was enhanced collaboration and teamwork among the 4 RT groups, as manifested by sharing of educational resources, developing a cross-departmental float pool, and forming a process and group to standardize RT care across all groups. CONCLUSIONS: The results of this business review process show that teamwork among 4 separate RT departments improved and that enhanced outcomes were achieved. Based on this experience, we recommend consideration of this business review process as a team-building activity that can confer demonstrable clinical benefits.

Efflux pump gene expression in Erwinia chrysanthemi is induced by exposure to phenolic acids.

Salicylic acid (SA) is an important signaling molecule in local and systemic plant resistance. Following infection by microbial pathogens and the initial oxidative burst in plants, SA accumulation functions in the amplification of defense gene expression. Production of pathogenesis-related proteins and toxic antimicrobial chemicals serves to protect the plant from infection. Successful microbial pathogens utilize a variety of mechanisms to rid themselves of toxic antimicrobial compounds. Important among these mechanisms are multidrug-resistance pumps that bring about the active efflux of toxic compounds from microbial cells. Here, we show that a combination SA and its precursors, t-cinnamic acid and benzoic acid, can activate expression of specific multidrug efflux pump-encoding genes in the plant pathogen Erwinia chrysanthemi and enhance survival of the bacterium in the presence of model as well as plant-derived antimicrobial chemicals. This ability of plant-pathogenic bacteria to co-opt plant defense-signaling molecules to activate multidrug efflux pumps may have evolved to ensure bacterial survival in susceptible host plants.