76
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Thibaudeau S, Gerety P, Levin S. Abstract P33. Plast Reconstr Surg 2015. [DOI: 10.1097/01.prs.0000464002.57870.96] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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77
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Bussière M, Kotylak T, Naik K, Levin S. Optic Nerve Enlargement Associated with Globoid Cell Leukodystrophy. Can J Neurol Sci 2014; 33:235-6. [PMID: 16736737 DOI: 10.1017/s0317167100005047] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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78
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Rossoni M, Levin S, Tay KY, Prasad AN. 98: Hanging, Choking and Near-Drowning in Children; Imaging Findings, Neurological Sequelae, and Outcomes. Paediatr Child Health 2014. [DOI: 10.1093/pch/19.6.e35-96] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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79
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Shetzer Y, Kagan S, Koifman G, Sarig R, Kogan-Sakin I, Charni M, Kaufman T, Zapatka M, Molchadsky A, Rivlin N, Dinowitz N, Levin S, Landan G, Goldstein I, Goldfinger N, Pe'er D, Radlwimmer B, Lichter P, Rotter V, Aloni-Grinstein R. The onset of p53 loss of heterozygosity is differentially induced in various stem cell types and may involve the loss of either allele. Cell Death Differ 2014; 21:1419-31. [PMID: 24832469 DOI: 10.1038/cdd.2014.57] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 02/27/2014] [Accepted: 03/17/2014] [Indexed: 12/12/2022] Open
Abstract
p53 loss of heterozygosity (p53LOH) is frequently observed in Li-Fraumeni syndrome (LFS) patients who carry a mutant (Mut) p53 germ-line mutation. Here, we focused on elucidating the link between p53LOH and tumor development in stem cells (SCs). Although adult mesenchymal stem cells (MSCs) robustly underwent p53LOH, p53LOH in induced embryonic pluripotent stem cells (iPSCs) was significantly attenuated. Only SCs that underwent p53LOH induced malignant tumors in mice. These results may explain why LFS patients develop normally, yet acquire tumors in adulthood. Surprisingly, an analysis of single-cell sub-clones of iPSCs, MSCs and ex vivo bone marrow (BM) progenitors revealed that p53LOH is a bi-directional process, which may result in either the loss of wild-type (WT) or Mut p53 allele. Interestingly, most BM progenitors underwent Mutp53LOH. Our results suggest that the bi-directional p53LOH process may function as a cell-fate checkpoint. The loss of Mutp53 may be regarded as a DNA repair event leading to genome stability. Indeed, gene expression analysis of the p53LOH process revealed upregulation of a specific chromatin remodeler and a burst of DNA repair genes. However, in the case of loss of WTp53, cells are endowed with uncontrolled growth that promotes cancer.
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80
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Toerper MF, Veltri MA, Hamrock E, Mollenkopf NL, Holt K, Levin S. Medication waste reduction in pediatric pharmacy batch processes. J Pediatr Pharmacol Ther 2014; 19:111-7. [PMID: 25024671 PMCID: PMC4093663 DOI: 10.5863/1551-6776-19.2.111] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To inform pediatric cart-fill batch scheduling for reductions in pharmaceutical waste using a case study and simulation analysis. METHODS A pre and post intervention and simulation analysis was conducted during 3 months at a 205-bed children's center. An algorithm was developed to detect wasted medication based on time-stamped computerized provider order entry information. The algorithm was used to quantify pharmaceutical waste and associated costs for both preintervention (1 batch per day) and postintervention (3 batches per day) schedules. Further, simulation was used to systematically test 108 batch schedules outlining general characteristics that have an impact on the likelihood for waste. RESULTS Switching from a 1-batch-per-day to a 3-batch-per-day schedule resulted in a 31.3% decrease in pharmaceutical waste (28.7% to 19.7%) and annual cost savings of $183,380. Simulation results demonstrate how increasing batch frequency facilitates a more just-in-time process that reduces waste. The most substantial gains are realized by shifting from a schedule of 1 batch per day to at least 2 batches per day. The simulation exhibits how waste reduction is also achievable by avoiding batch preparation during daily time periods where medication administration or medication discontinuations are frequent. Last, the simulation was used to show how reducing batch preparation time per batch provides some, albeit minimal, opportunity to decrease waste. CONCLUSIONS The case study and simulation analysis demonstrate characteristics of batch scheduling that may support pediatric pharmacy managers in redesign toward minimizing pharmaceutical waste.
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81
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Kogan A, Preisman S, Levin S, Raanani E, Sternik L. Adult respiratory distress syndrome following cardiac surgery. J Card Surg 2013; 29:41-6. [PMID: 24299028 DOI: 10.1111/jocs.12264] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Severe lung injury with the development of acute respiratory distress syndrome (ARDS) is a serious complication of cardiac surgery. The aim of this study was to determine the incidence, risk factors, and mortality of ARDS following cardiac surgery. METHODS We retrospectively analyze data in the period between January 2005 and March 2013. RESULTS Of 6069 patients who underwent cardiac surgery during the study period, 37 patients developed ARDS during the postoperative period. The incidence of ARDS was 0.61%, with a mortality of 40.5% (15 patients). Multivariate regression analysis identified previous cardiac surgery, complex cardiac surgery, and more than three transfusions with packed red blood cells (PRBC) were independent predictors for developing ARDS. CONCLUSIONS ARDS remains a serious, but very rare complication associated with significant mortality. In our study, previous cardiac surgery, complex cardiac surgery, and more than three transfusions of PRBC were independent predictors for the development of ARDS.
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82
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Bayram JD, Sauer LM, Catlett C, Levin S, Cole G, Kirsch TD, Toerper M, Kelen G. Critical resources for hospital surge capacity: an expert consensus panel. PLOS CURRENTS 2013; 5. [PMID: 24162793 PMCID: PMC3805833 DOI: 10.1371/currents.dis.67c1afe8d78ac2ab0ea52319eb119688] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background: Hospital surge capacity (HSC) is dependent on the ability to increase or conserve resources. The hospital surge model put forth by the Agency for Healthcare Research and Quality (AHRQ) estimates the resources needed by hospitals to treat casualties resulting from 13 national planning scenarios. However, emergency planners need to know which hospital resource are most critical in order to develop a more accurate plan for HSC in the event of a disaster.
Objective: To identify critical hospital resources required in four specific catastrophic scenarios; namely, pandemic influenza, radiation, explosive, and nerve gas.
Methods: We convened an expert consensus panel comprised of 23 participants representing health providers (i.e., nurses and physicians), administrators, emergency planners, and specialists. Four disaster scenarios were examined by the panel. Participants were divided into 4 groups of five or six members, each of which were assigned two of four scenarios. They were asked to consider 132 hospital patient care resources- extracted from the AHRQ's hospital surge model- in order to identify the ones that would be critical in their opinion to patient care. The definition for a critical hospital resource was the following: absence of the resource is likely to have a major impact on patient outcomes, i.e., high likelihood of untoward event, possibly death. For items with any disagreement in ranking, we conducted a facilitated discussion (modified Delphi technique) until consensus was reached, which was defined as more than 50% agreement. Intraclass Correlation Coefficients (ICC) were calculated for each scenario, and across all scenarios as a measure of participant agreement on critical resources. For the critical resources common to all scenarios, Kruskal-Wallis test was performed to measure the distribution of scores across all scenarios.
Results: Of the 132 hospital resources, 25 were considered critical for all four scenarios by more than 50% of the participants. The number of hospital resources considered to be critical by consensus varied from one scenario to another; 58 for the pandemic influenza scenario, 51 for radiation exposure, 41 for explosives, and 35 for nerve gas scenario. Intravenous crystalloid solution was the only resource ranked by all participants as critical across all scenarios. The agreement in ranking was strong in nerve agent and pandemic influenza (ICC= 0.7 in both), and moderate in explosives (ICC= 0.6) and radiation (ICC= 0.5).
Conclusion: In four disaster scenarios, namely, radiation, pandemic influenza, explosives, and nerve gas scenarios; supply of as few as 25 common resources may be considered critical to hospital surge capacity. The absence of any these resources may compromise patient care. More studies are needed to identify critical hospital resources in other disaster scenarios.
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Mishra S, Barnard ND, Gonzales J, Xu J, Agarwal U, Levin S. Nutrient intake in the GEICO multicenter trial: the effects of a multicomponent worksite intervention. Eur J Clin Nutr 2013; 67:1066-71. [PMID: 23942177 PMCID: PMC3790252 DOI: 10.1038/ejcn.2013.149] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 07/17/2013] [Accepted: 07/18/2013] [Indexed: 11/15/2022]
Abstract
BACKGROUND/OBJECTIVES To assess the effects on macro- and micronutrient intake of a nutrition intervention program in corporate settings across the United States. SUBJECTS/METHODS Two hundred and ninety-two individuals who were overweight or had type 2 diabetes were recruited from 10 sites of a US insurance company. Two hundred and seventy-one participants completed baseline diet recalls, and 183 participants completed dietary recalls at 18 weeks. Sites were randomly assigned to an intervention group (five sites) or to a control group (five sites) for 18 weeks. At intervention sites, participants were asked to follow a low-fat vegan diet and attend weekly group meetings. At control sites, participants continued their usual diets. At baseline and 18 weeks, participants completed 2-day diet recalls. Between-group differences in changes in nutrient intake were assessed using an analysis of covariance. RESULTS Compared with those in the control group, intervention-group participants significantly reduced the reported intake of total fat (P=0.02), saturated (P=0.006) and monounsaturated fats (P=0.01), cholesterol (P=0.009), protein (P=0.03) and calcium (P=0.02), and increased the intake of carbohydrate (P=0.006), fiber (P=0.002), β-carotene (P=0.01), vitamin C (P=0.003), magnesium (P=0.04) and potassium (P=0.002). CONCLUSIONS An 18-week intervention program in a corporate setting reduces intake of total fat, saturated fat and cholesterol and increases the intake of protective nutrients, particularly fiber, β-carotene, vitamin C, magnesium and potassium. The reduction in calcium intake indicates the need for planning for this nutrient.
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84
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Firnhaber C, Mao L, Lewis DA, Goeieman B, Swarts A, Faesen M, Levin S, Rakhombe N, Williams S, Smith JS. P5.042 Quality Assurance in Visual Inspection of the Cervix - the South African Experience. Br J Vener Dis 2013. [DOI: 10.1136/sextrans-2013-051184.1086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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85
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Mishra S, Xu J, Agarwal U, Gonzales J, Levin S, Barnard ND. A multicenter randomized controlled trial of a plant-based nutrition program to reduce body weight and cardiovascular risk in the corporate setting: the GEICO study. Eur J Clin Nutr 2013; 67:718-24. [PMID: 23695207 PMCID: PMC3701293 DOI: 10.1038/ejcn.2013.92] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Revised: 03/29/2013] [Accepted: 04/04/2013] [Indexed: 12/31/2022]
Abstract
Background/objectives: To determine the effects of a low-fat plant-based diet program on anthropometric and biochemical measures in a multicenter corporate setting. Subjects/methods: Employees from 10 sites of a major US company with body mass index ⩾25 kg/m2 and/or previous diagnosis of type 2 diabetes were randomized to either follow a low-fat vegan diet, with weekly group support and work cafeteria options available, or make no diet changes for 18 weeks. Dietary intake, body weight, plasma lipid concentrations, blood pressure and glycated hemoglobin (HbA1C) were determined at baseline and 18 weeks. Results: Mean body weight fell 2.9 kg and 0.06 kg in the intervention and control groups, respectively (P<0.001). Total and low-density lipoprotein (LDL) cholesterol fell 8.0 and 8.1 mg/dl in the intervention group and 0.01 and 0.9 mg/dl in the control group (P<0.01). HbA1C fell 0.6 percentage point and 0.08 percentage point in the intervention and control group, respectively (P<0.01). Among study completers, mean changes in body weight were −4.3 kg and −0.08 kg in the intervention and control groups, respectively (P<0.001). Total and LDL cholesterol fell 13.7 and 13.0 mg/dl in the intervention group and 1.3 and 1.7 mg/dl in the control group (P<0.001). HbA1C levels decreased 0.7 percentage point and 0.1 percentage point in the intervention and control group, respectively (P<0.01). Conclusions: An 18-week dietary intervention using a low-fat plant-based diet in a corporate setting improves body weight, plasma lipids, and, in individuals with diabetes, glycemic control.
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86
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Dugas AF, Jalalpour M, Gel Y, Levin S, Torcaso F, Igusa T, Rothman R. Influenza Forecasting with Google Flu Trends. Online J Public Health Inform 2013. [PMCID: PMC3692885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective We sought to develop a practical influenza forecast model, based on real-time, geographically focused, and easy to access data, to provide individual medical centers with advanced warning of the number of influenza cases, thus allowing sufficient time to implement an intervention. Secondly, we evaluated how the addition of a real-time influenza surveillance system, Google Flu Trends, would impact the forecasting capabilities of this model. Introduction Each year, influenza results in increased Emergency Department crowding which can be mitigated through early detection linked to an appropriate response. Although current surveillance systems, such as Google Flu Trends, yield near real-time influenza surveillance, few demonstrate ability to forecast impending influenza cases. Methods Forecasting models designed to predict one week in advance were developed from weekly counts of confirmed influenza cases over seven seasons (2004 – 2011) divided into training and out-of-sample verification sets. Forecasting procedures using classical Box-Jenkins, generalized linear, and autoregressive methods were employed to develop the final model and assess the relative contribution of external variables such as, Google Flu Trends, meteorological data, and temporal information. Models were developed and evaluated through statistical measures of global deviance and log-likelihood ratio tests. An additional measure of forecast confidence, defined as the percentage of forecast values, during an influenza peak, that are within 7 influenza cases of the actual data, was examined to demonstrate practical utility of the model. Results A generalized autoregressive Poisson (GARMA) forecast model integrating previous influenza cases with Google Flu Trends information provided the most accurate influenza case predictions. Google Flu Trend data was the only source of external information providing significant forecast improvements (p = 0.00002). The final model, a GARMA intercept model with the addition of Google Flu Trends, predicted weekly influenza cases during 4 out-of-sample outbreaks within 7 cases for 80% of estimates (Figure 1). Conclusions Integer-valued autoregression of influenza cases provides a strong base forecast model, which is enhanced by the addition of Google Flu Trends confirming the predictive capabilities of search query based syndromic surveillance. This accessible and flexible forecast model can be used by individual medical centers to provide advanced warning of future influenza cases.
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87
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Hamrock E, Paige K, Parks J, Scheulen J, Levin S. Discrete event simulation for healthcare organizations: a tool for decision making. J Healthc Manag 2013; 58:110-125. [PMID: 23650696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Healthcare organizations face challenges in efficiently accommodating increased patient demand with limited resources and capacity. The modern reimbursement environment prioritizes the maximization of operational efficiency and the reduction of unnecessary costs (i.e., waste) while maintaining or improving quality. As healthcare organizations adapt, significant pressures are placed on leaders to make difficult operational and budgetary decisions. In lieu of hard data, decision makers often base these decisions on subjective information. Discrete event simulation (DES), a computerized method of imitating the operation of a real-world system (e.g., healthcare delivery facility) over time, can provide decision makers with an evidence-based tool to develop and objectively vet operational solutions prior to implementation. DES in healthcare commonly focuses on (1) improving patient flow, (2) managing bed capacity, (3) scheduling staff, (4) managing patient admission and scheduling procedures, and (5) using ancillary resources (e.g., labs, pharmacies). This article describes applicable scenarios, outlines DES concepts, and describes the steps required for development. An original DES model developed to examine crowding and patient flow for staffing decision making at an urban academic emergency department serves as a practical example.
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88
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Dugas AF, Jalalpour M, Gel Y, Levin S, Torcaso F, Igusa T, Rothman RE. Influenza forecasting with Google Flu Trends. PLoS One 2013; 8:e56176. [PMID: 23457520 PMCID: PMC3572967 DOI: 10.1371/journal.pone.0056176] [Citation(s) in RCA: 168] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Accepted: 01/07/2013] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND We developed a practical influenza forecast model based on real-time, geographically focused, and easy to access data, designed to provide individual medical centers with advanced warning of the expected number of influenza cases, thus allowing for sufficient time to implement interventions. Secondly, we evaluated the effects of incorporating a real-time influenza surveillance system, Google Flu Trends, and meteorological and temporal information on forecast accuracy. METHODS Forecast models designed to predict one week in advance were developed from weekly counts of confirmed influenza cases over seven seasons (2004-2011) divided into seven training and out-of-sample verification sets. Forecasting procedures using classical Box-Jenkins, generalized linear models (GLM), and generalized linear autoregressive moving average (GARMA) methods were employed to develop the final model and assess the relative contribution of external variables such as, Google Flu Trends, meteorological data, and temporal information. RESULTS A GARMA(3,0) forecast model with Negative Binomial distribution integrating Google Flu Trends information provided the most accurate influenza case predictions. The model, on the average, predicts weekly influenza cases during 7 out-of-sample outbreaks within 7 cases for 83% of estimates. Google Flu Trend data was the only source of external information to provide statistically significant forecast improvements over the base model in four of the seven out-of-sample verification sets. Overall, the p-value of adding this external information to the model is 0.0005. The other exogenous variables did not yield a statistically significant improvement in any of the verification sets. CONCLUSIONS Integer-valued autoregression of influenza cases provides a strong base forecast model, which is enhanced by the addition of Google Flu Trends confirming the predictive capabilities of search query based syndromic surveillance. This accessible and flexible forecast model can be used by individual medical centers to provide advanced warning of future influenza cases.
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89
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Levin S, Sauer L, Kelen G, Kirsch T, Pham J, Desai S, France D. Situation awareness in emergency medicine. ACTA ACUST UNITED AC 2012. [DOI: 10.1080/19488300.2012.684739] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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90
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Dugas A, Hsieh YH, Levin S, Pines J, Mareiniss D, Mohareb A, Gaydos C, Perl T, Rothman R. Google flu trends: correlation with emergency department influenza rates and crowding metrics. EMERGING HEALTH THREATS JOURNAL 2011. [DOI: 10.3402/ehtj.v4i0.11187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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91
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France D, Levin S, Ding R, Hemphill R, Han J, Russ S, Aronsky D, Weinger MB. Abstract P157: Factors Influencing Time-Dependent Quality Indicators for Suspected ACS Patients in the ED. Circ Cardiovasc Qual Outcomes 2011. [DOI: 10.1161/circoutcomes.4.suppl_2.ap157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Rapid risk stratification and timely treatment are critical to favorable outcomes for acute coronary syndrome (ACS) patients. This study examines five time-dependent quality indicators (QIs) for unstable angina (UA) / non-ST elevation (NSTEMI) patients in the ED. Our objective was to determine patient and system factors that influence QIs (see Table1) for timeliness for ED UA/NSTEMI patients.
Methods:
A retrospective, cohort study was conducted at an academic medical center ED over a 2 year period. The cohort consisted of all patients (N=12,544) aged 24 years or older suspected of having ACS as defined by receiving an electrocardiogram (ECG) and at least one cardiac biomarker test. Cox regression was used to model the effects of patient characteristics, ancillary service utilization, staffing provisions, equipment availability and metrics characterizing ED and hospital crowding on time-dependent QIs.
Results:
UA/NSTEMI patient QI times and percentage adherence to defined performance standards are displayed in Table 1. Table 2 shows the factors that most influenced ED performance on each QI, a description of how each factor changed, and the resultant change in QI time interval. Average change in indicator time was calculated using the full Cox regression model created for each indicator, thus adjusting for all other significant factors.
Quality Indicator
Definition
Performance Standard
Time: Median (IQR) min
% Adherence
1. ECG read out time (Suspected of UA/NSTEMI - ECG and Biomarker)
Arrival time to ECG read out time
< = 10 min
13 (7 - 32)
42%
2. Lab turn-around-time
Physician biomarker order to lab report time
< = 60 min
70 (53 - 96)
37%
3. Therapeutic
__turn-around-time (overall)
Physician biomarker order to first anti-ischemic medication administration
Not defined
30 (14 - 66)
–
3b. Therapeutic
__turn-around-time (Anti-platelet))
Physician biomarker order to first anti-ischemic medication administration
Not defined
173 (71 - 317)
–
3c. Therapeutic
__turn-around-time (Anti-thrombin)
Physician biomarker order to first anti-ischemic medication administration
Not defined
30 (14 - 65)
–
4. Boarding time
Disposition decision time to inpatient admit time for admitted patients
< = 120 min
198 (97 - 496)
32%
5. ED length of stay
Arrival time to discharge (disposition decision for inpatients)
Not defined
247 (156 - 392)
–
Quality Indicator
Factor
Change in Factor
Hazard Ratio
Median Ä in Minutes (%)
1. ECG read out time
Chief Complaint
Chief Complaint
Acuity
Acuity
Non-chest pain related compared to chest pain
Chest pain related compared to chest pain
Level 1 compared to levels 3 to 5
Level 2 compared to levels 3 to 5
0.35
0.58
1.83
1.36
17.0
5.0
-2.4
-1.4
2. Lab turn-around-time
Cardiologist in ED
Time of Day
Time of Day
Point of Care Testing
Team Triage
Cardiologist present in ED compared to not present
Night compared to day
Evening compared to day
Point of care compared to standard lab
Team triage compared to not active
0.74
0.84
0.89
1.15
1.12
8.0
4.5
3.0
-3.0
-2.4
3. Therapeutic turn-around-time
Stress Test
Chief Complaint
Chief Complaint
Non-portable Chest
X-ray
Stress test prior to med administration compared to none
Non-chest pain related compared to chest pain
Chest pain related compared to chest pain
Non-portable chest X-ray prior to med administration compare to none
0.41
0.60
0.72
0.82
163.8
67.7
39.2
20.5
4. ED Boarding Time
Med Administration
Patient Insurance
Patient Insurance
Time of Day
Patient Insurance
Telemetry Occupancy
Time of Day
Acuity
Cardiology consult placeHoliday
Portable Chest X-Ray
Acuity
Med Administration
Med administration before disposition compared to no med administration
Self pay compared to commercial
Medicaid compared to commercial
Night Compared to day
Medicare compared to commercial
10% increase in telemetry occupancy
Evening compared to day
Level 1 compared to levels 3 to 5
Consultant used compared to none
placeHoliday compare to non holiday
Portable Chest X-ray before disposition compared to no X-ray
Level 2 compared to levels 3 to 5
Med administration after disposition
Compared to no med administration
1.09
0.84
0.81
0.84
0.88
0.28
0.97
3.83
1.37
1.33
1.19
1.15
0.77
63.3
48.4
39.6
38.4
27.8
27.7
6.7
-135.5
-48.1
-44.1
-29.5
-24.1
-14.6
5. ED length of stay
Stress Test
Point of Care Testing
Age 45 - 54 Years
Age 35 - 44 Years
Chief Complaint
Time of Day
Admitted Chief Complaint
ED chest pain occupancy
Stress test prior to disposition decision compared to none
Point of care compared to standard lab
45 - 54 years compared to > 64 years
35 -44 years compared to > 64 years
Not chest pain-related compared to chest pain-related
Evening
Admitted compared to discharged
Chest pain-related compare to not related to chest pain Percent increase in ED chest pain/neurology load
0.36
0.78
0.81
0.81
0.87
0.88
1.70
1.11
1.01
171.0
30.2
26.0
25.2
17.6
15.0
-50.5
-10.7
-2.9
Conclusions:
The natural variability (not amenable to change) of patient and clinical factors and the artificial variability created by man-made processes and systems (amenable to change) both significantly influenced QI times for our ED UA/NSTEMI cohort. ECG time was the only QI influenced solely by patient factors.
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Parks JK, Engblom P, Hamrock E, Satjapot S, Levin S. Designed to fail: how computer simulation can detect fundamental flaws in clinic flow. J Healthc Manag 2011; 56:135-146. [PMID: 21495531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Discrete-event simulation can be used as an effective tool for healthcare administrators to "test" various operational decisions. The recent growth in hospital outpatient volumes and a constrained financial environment make discrete-event simulation a cost-effective way to diagnose inefficiency and create and test strategies for improvement. This study shows how discrete-event simulation was used in an adult medicine clinic within a large, tertiary care, academic medical center. Simulation creation steps are discussed, including information gathering, process mapping, data collection, model creation, and results. Results of the simulation indicated that system bottle-necks were present in the medication administration and check-out steps of the clinic process. The simulation predicted that matching resources to excessive demand at appropriate times for these bottleneck steps would reduce patients' mean time in the system (i.e., visit time) from 124.3 (s.d. +/- 65.7) minutes to 87.0 (s.d. +/- 36.4) minutes. Although other factors may affect real-world operations of a clinic, discrete-event simulation allows healthcare administrators and clinic operational decision makers to observe the effects of changing staffing and resource allocations on patient wait and throughput time. Discrete-event simulation is not a cure-all for clinic throughput problems, but can be a strong tool to provide evidentiary guidance for clinic operational redesign.
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Levin S, Dittus R, Aronsky D, Weinger M, France D. Evaluating the effects of increasing surgical volume on emergency department patient access. BMJ Qual Saf 2011; 20:146-52. [PMID: 21209127 DOI: 10.1136/bmjqs.2008.030007] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIM To determine how increases in surgical patient volume will affect emergency department (ED) access to inpatient cardiac services. To compare how strategies to increase cardiology inpatient throughput can either accommodate increases in surgical volume or improve ED patient access. METHODS A stochastic discrete event simulation was created to model patient flow through a cardiology inpatient system within a US, urban, academic hospital. The simulation used survival analysis to examine the relationship between anticipated increases in surgical volume and ED patient boarding time (ie, time interval from cardiology admission request to inpatient bed placement). RESULTS ED patients boarded for a telemetry and cardiovascular intensive care unit (CVICU) bed had a mean boarding time of 5.3 (median 3.1, interquartile range 1.5-6.9) h and 2.7 (median 1.7, interquartile range 0.8-3.0) h, respectively. Each 10% incremental increase in surgical volume resulted in a 37 and 33 min increase in mean boarding time to the telemetry unit and CVICU, respectively. Strategies to increase cardiology inpatient throughput by increasing capacity and decreasing length of stay for specific inpatients was compared. Increasing cardiology capacity by one telemetry and CVICU bed or decreasing length of stay by 1 h resulted in a 7-9 min decrease in average boarding time or an 11-19% increase in surgical patient volume accommodation. CONCLUSIONS Simulating competition dynamics for hospital admissions provides prospective planning (ie, decision making) information and demonstrates how interventions to increase inpatient throughput will have a much greater effect on higher priority surgical admissions compared with ED admissions.
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Ferdowsian HR, Levin S. Does diet really affect acne? SKIN THERAPY LETTER 2010; 15:1-5. [PMID: 20361171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Acne vulgaris has anecdotally been attributed to diet by individuals affected by this skin condition. In a 2009 systematic literature review of 21 observational studies and 6 clinical trials, the association between acne and diet was evaluated. Observational studies, including 2 large controlled prospective trials, reported that cow's milk intake increased acne prevalence and severity. Furthermore, prospective studies, including randomized controlled trials, demonstrated a positive association between a high-glycemic-load diet, hormonal mediators, and acne risk. Based on these findings, there exists convincing data supporting the role of dairy products and high-glycemic-index foods in influencing hormonal and inflammatory factors, which can increase acne prevalence and severity. Studies have been inconclusive regarding the association between acne and other foods.
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95
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Stone D, Moberg P, Respicio G, Levin S, Rooney T. Pericarditis with cardiac tamponade in systemic lupus erythematosus. Development immediately following successful control of lupus flare. Lupus 2009; 19:890-1. [PMID: 20026521 DOI: 10.1177/0961203309357976] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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96
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Sackley C, Hoppitt T, Cardoso K, Levin S. The availability and use of allied health care in care homes in the Midlands, UK. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2009. [DOI: 10.12968/ijtr.2009.16.4.41195] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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97
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Banwell B, Kennedy J, Sadovnick D, Arnold DL, Magalhaes S, Wambera K, Connolly MB, Yager J, Mah JK, Shah N, Sebire G, Meaney B, Dilenge ME, Lortie A, Whiting S, Doja A, Levin S, MacDonald EA, Meek D, Wood E, Lowry N, Buckley D, Yim C, Awuku M, Guimond C, Cooper P, Grand'Maison F, Baird JB, Bhan V, Bar-Or A. Incidence of acquired demyelination of the CNS in Canadian children. Neurology 2009; 72:232-9. [DOI: 10.1212/01.wnl.0000339482.84392.bd] [Citation(s) in RCA: 232] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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98
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Germann G, Sauerbier M, Schepler H, Levin S. Intrinsic Flaps in Soft Tissue Reconstruction of the Hand. Semin Plast Surg 2008. [DOI: 10.1055/s-2008-1080255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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99
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Levin S, Aronsky D, Hemphill R, Han J, Slagle J, France DJ. Shifting Toward Balance: Measuring the Distribution of Workload Among Emergency Physician Teams. Ann Emerg Med 2007; 50:419-23. [PMID: 17559969 DOI: 10.1016/j.annemergmed.2007.04.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2006] [Revised: 03/14/2007] [Accepted: 04/06/2007] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVE The objective of this investigation is to determine time-dependent workload patterns for emergency department (ED) physician teams across work shifts. A secondary aim was to demonstrate how ED demand patterns and the timing of shift changes influence the balance of workload among a physician team. METHODS Operational measurements of an adult ED were collected from a clinical information system to characterize physician workload patterns during all current work shifts. Plots of patient load versus time were developed for each physician shift, in which patient load was defined as the number of patients a physician simultaneously managed at a point in time. Patient-load curves for each shift were superimposed during 24 hours to display how patient load was distributed among a team of physicians. RESULTS Resident shift changes during daily peak occupancy periods caused patient load imbalances so that residents on a particular shift consistently managed a disproportionate number of patients (mean 9.4 patients; 95% confidence interval [CI] 6.7 to 12.1 patients) compared with other residents on duty (mean 3.4 patients; 95% CI 2.1 to 4.7 patients). CONCLUSION Physician patient load patterns and ED demand patterns should be taken into consideration when physician shift times are scheduled so that patient load may be balanced among a team. Real-time monitoring of physician patient load may reduce stress and prevent physicians from exceeding their safe capacity for workload.
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France DJ, Levin S. System complexity as a measure of safe capacity for the emergency department. Acad Emerg Med 2006; 13:1212-9. [PMID: 16807398 DOI: 10.1197/j.aem.2006.04.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVES System complexity is introduced as a new measure of system state for the emergency department (ED). In its original form, the measure quantifies the uncertainty of demands on system resources. For application in the ED, the measure is being modified to quantify both workload and uncertainty to produce a single integrated measure of system state. METHODS Complexity is quantified using an information-theoretic or entropic approach developed in manufacturing and operations research. In its original form, complexity is calculated on the basis of four system parameters: 1) the number of resources (clinicians and processing entities such as radiology and laboratory systems), 2) the number of possible work states for each resource, 3) the probability that a resource is in a particular work state, and 4) the probability of queue changes (i.e., where a queue is defined by the number of patients or patient orders being managed by a resource) during a specified time period. RESULTS An example is presented to demonstrate how complexity is calculated and interpreted for a simple system composed of three resources (i.e., emergency physicians) managing varying patient loads. The example shows that variation in physician work states and patient queues produces different scores of complexity for each physician. It also illustrates how complexity and workload differ. CONCLUSIONS System complexity is a viable and technically feasible measurement for monitoring and managing surge capacity in the ED.
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