Reflective Practice: A Tool for Readmission Reduction.

Factors intrinsic to local practice, but not captured by the medical record, contribute to readmissions. Frontline providers familiar with their practice systems can identify these. The objective was to decrease 30-day hospital readmissions. The intervention involved retrospective review by hospitalists of their own patients' readmissions, using reflective practice guided by a chart review tool. Subjects were patients discharged by hospitalists and readmitted to a tertiary care academic medical center. Hospitalists reviewed 193 readmissions of 170 patients. Factors contributing to readmission were grouped under patient characteristics, operational factors, and care transition. After reflection, physicians scheduled earlier follow-up appointments while nurse practitioners and physician assistants improved discharge instructions. Readmissions decreased during the review period, and the decrease sustained for one year after the review period. Hospitalists reflected on and identified local practice factors that contributed to their own patients' 30-day readmissions. Reflective practice may be an effective strategy to decrease hospital readmissions.

Posthospital follow-up visits and 30-day readmission rates in chronic obstructive pulmonary disease.

PURPOSE: To examine the effect of a follow-up visit with a primary care physician and/or pulmonologist within the first 30 days of hospital discharge on readmissions, emergency department (ED) visits, and mortality. PATIENTS AND METHODS: This was a retrospective cohort study of 7,102 unique patients discharged from a Mayo Clinic hospital in Rochester, MN, and residing in Olmsted County, MN, with any mention of chronic obstructive pulmonary disease (COPD) from January 1, 2004 through November 30, 2011. The study included 839 patients who met study-entry criteria. Cox proportional hazards regression was performed to determine the risk of hospital readmission, ED visits, and death of patients, with or without a follow-up visit during the first 30 days postdischarge. RESULTS: Our results showed 839 unique patients experienced 1,422 discharges with a primary diagnosis of COPD. Of the 1,422 discharges, 973 (68.4%) had a follow-up visit within 30 days. In a multivariate Cox proportional hazard-ratio (HR) model analysis, occurrence of a follow-up visit did not have a significant effect on the risk of the combined outcome of 30-day readmission and ED visit (HR 0.947, confidence interval 0.763-1.177; P=0.63). However, a postdischarge follow-up visit had a significant effect on 30-day mortality (HR 0.279, confidence interval 0.149-0.523; P<0.001). CONCLUSION: Postdischarge follow-up visits after hospitalization for COPD did not significantly reduce the risk of 30-day readmission or ED visit. However, patients who received postdischarge follow-up visits had significantly reduced 30-day mortality.

Attitudes of nursing staff toward interprofessional in-patient-centered rounding.

Historically, medicine and nursing has had a hierarchical and patriarchal relationship, with physicians holding monopoly over knowledge-based practice of medical care, thus impeding interprofessional collaboration. Power gradient prevents nurses from demanding cooperative patient rounding. We surveyed attitudes of nursing staff at our tertiary care community hospital, before and after implementation of a patient-centered interprofessional (hospitalist-nurse) rounding process for patients. There was a substantial improvement in nursing staff satisfaction related to the improved communication (7%-54%, p < 0.001) and rounding (3%-49%, p < 0.001) by hospitalist providers. Patient-centered rounding also positively impacted nursing workflow (5%-56%, p < 0.001), nurses' perceptions of value as a team member (26%-56%, p = 0.018) and their job satisfaction (43%-59%, p = 0.010). Patient-centered rounding positively contributed to transforming the hospitalist-nurse hierarchical model to a team-based collaborative model, thus enhancing interprofessional relationships.

Material properties of photomechanical infrared receptors in pyrophilous Melanophila beetles and Aradus bugs.

Jewel beetles of the genus Melanophila and some pyrophilous species of the flat bugs genus Aradus show a pyrophilous behaviour and have developed so-called photomechanical infrared (IR) receptors. In a spherical photomechanical IR sensillum incoming IR radiation is converted into micromechanical action, finally stimulating the dendritic tip of a mechanosensitive sensory cell. The tip is located inside a tiny cuticular sphere with a diameter of about 12 µm. The material properties of the different cuticular components of this sphere are of great importance for stimulus generation. We measured the modulus and hardness of the outer exocuticular shell of the sphere and the mesocuticle inside the core. Measurements were made by nanoindentation at sensilla which were partly cut open under dry as well as under rewetted (i.e. quasi-natural) conditions. We found that in the rewetted sensilla the outer exocuticular shell of the sphere in the Melanophila sensillum is about 50% harder and 20% stiffer than reference exocuticle, and that in both species especially the rewetted mesocuticle of the inner core of the IR sensilla is significantly softer (about 80% in Melanophila) and more compliant (about 90% also in Melanophila) than the reference mesocuticle. The findings can be interpreted as special adaptations of the cuticular microdomains of photomechanical infrared sensilla to enhance thermomechanical performance and, thereby, sensitivity.

Infrared receptors in pyrophilous ("fire loving") insects as model for new un-cooled infrared sensors.

Beetles of the genus Melanophila and certain flat bugs of the genus Aradus actually approach forest fires. For the detection of fires and of hot surfaces the pyrophilous species of both genera have developed infrared (IR) receptors, which have developed from common hair mechanoreceptors. Thus, this type of insect IR receptor has been termed photomechanic and shows the following two special features: (i) The formation of a complex cuticular sphere consisting of an outer exocuticular shell as well as of a cavernous microfluidic core and (ii) the enclosure of the dendritic tip of the mechanosensitive neuron inside the core in a liquid-filled chamber. Most probably a photomechanic IR sensillum acts as a microfluidic converter of infrared radiation which leads to an increase in internal pressure inside the sphere, which is measured by a mechanosensitive neuron.A simple model for this biological IR sensor is a modified Golay sensor in which the gas has been replaced by a liquid. Here, the absorbed IR radiation results in a pressure increase of the liquid and the deflection of a thin membrane. For the evaluation of this model analytical formulas are presented, which permits the calculation of the pressure increase in the cavity, the deformation of the membrane and the time constant of an artificial leak to compensate ambient temperature changes. Some organic liquids with high thermal expansion coefficients may improve the deflection of the membrane compared to water.

Water as a major modulator of the mechanical properties of insect cuticle.

The mechanical properties of the sternal cuticle of the locust were investigated by nanoindentation. Modulus and hardness of the exo-, meso-, and endocuticular layers were locally measured under dry and fully wetted conditions in the normal (i.e. perpendicular to the outer surface) as well as in the transverse direction (i.e. parallel to the alignment of the respective layers). The results show that water has a major impact on the mechanical properties of all layers. After drying the endocuticle, in particular, became harder by a factor of up to 9 and stiffer by a factor of up to 7.4. Additionally the gradual decrease in hardness and Young's modulus from the outer exo- to the inner endocuticle, characteristic of native cuticle, was eliminated or even reversed in dried cuticle. A pronounced anisotropy was revealed in all layers when comparing data obtained by probing in the normal (lower values) vs. probing in the transverse direction (higher values). Cyclic drying and rewetting of the endocuticle showed that the mechanical properties can be reproducibly changed by altering the water content. Based on our results we propose a new role of the epicuticle: fine-tuning of the mechanical properties of the different cuticular layers can be accomplished by setting the local cuticular transpiration.