Renovating Healthcare Facility Maintenance Planning: A Case Study From Walter Reed National Military Medical Center (WRNMMC).

PURPOSE: This article documents the development and implementation of a new approach for health facilities construction and maintenance planning, the use of a Facilities and Clinical Coordination (FCC) Council, at Walter Reed National Military Medical Center (WRNMMC). BACKGROUND: WRNMMC is preparing for the largest and most complex renovation project in recent Department of Defense history. There is sparse documentation demonstrating stepwise frameworks for the implementation of effective and efficient health facilities maintenance management tools and techniques. METHOD: This study discusses the development and evaluation of the FCC Council. Clarity to the literature sources guiding the development of the FCC Council is provided, followed by the survey approach undertaken to assess Council efficacy based on participants' perceptions. Data are analyzed using descriptive and inferential statistics. RESULTS: Our study suggests routine cross-functional synchronous FCC Council meetings improve perceptions of safety and communication, encourage teamwork, and are more productive when conducted using synchronous rather than asynchronous communication. Clinician participants strongly supported the face-to-face meeting approach and considered such meetings more effective as they are perceived to maintain staff and patient safety as a constant organizational focus. CONCLUSION: The FCC's perceived effectiveness toward improving healthcare facilities maintenance planning centers on engaged leadership, the inclusion of diverse subject matter experts, and structured group facilitation. Our results inform health facilities planners of the value the FCC Council brings to an organization by helping to develop organizational buy-in for major facilities renovation projects.

A reason to renovate: The association between hospital age of plant and value-based purchasing performance.

BACKGROUND/PURPOSE: Value-based purchasing (VBP) is increasing in influence in the health care industry; however, questions remain regarding the structural factors associated with improved performance. This study evaluates the association between age of hospital infrastructure and VBP outcomes. METHODOLOGY: Data on 1,911 hospitals from three sources (the American Hospital Association Annual Survey Database, the American Hospital Association DataViewer Financial Module, and the Centers for Medicare & Medicaid Services Hospital VBP Total Performance Scores data set) were evaluated. Age of health care facilities was represented by the "average age of plant" financial ratio. VBP performance was measured by an aggregate Total Performance Score composed of four equally weighted domains, including Efficiency and Cost Reduction, Clinical Care, Patient- and Caregiver-Centered Experience, and Patient Safety. We hypothesize that average age of plant is negatively correlated with each of these measures. RESULTS: Hospitals within the lowest quartile of average age of plant (0-8.13 years) were found to have a total Performance Score of 2.35 points higher than hospitals with a an average age of plant in the fourth quartile (14.63 years and above; R = 21.5%; p < .001) while controlling for hospital ownership, size, teaching status, geographic location, service mix, case mix, length of stay, community served, and labor force relative cost. Comparable results were found within the VBP domains, specifically for Clinical Care (ß = 4.09, p < .001) and Patient Experience (ß = 3.41, p < .001). Findings for the Patient Safety and Efficiency domains were not significant. A secondary and more granular examination of capitalized assets indicates organizations with higher building asset accumulated depreciation per bed in service were associated with lower total performance (ß = -.25, p < .001), Clinical Care (ß = -.31, p < .05), and Patient Experience scores (ß = -.45, p < .001). CONCLUSIONS: The results of this study provide evidence of an inverse association between a hospital's age of plant and specific elements of VBP performance. PRACTICE IMPLICATIONS: To date, no studies have investigated the relationship between hospital age of plant and value-based care. The results of our study may serve as supportive foundational evidence for health care leaders to target future capital investments to improve VBP outcomes.

Doing well by doing good: Evaluating the influence of patient safety performance on hospital financial outcomes.

BACKGROUND: As financial pressures on hospitals increase because of changing reimbursement structures and heightened focus on quality and value, the association between patient safety performance and financial outcomes remains unclear. PURPOSE: The purpose of this study is to investigate if hospitals with higher patient safety performance are associated with higher levels of profitability than those with lower safety performance. METHODOLOGY/APPROACH: Using multinomial logistic regression, we analyzed data from the spring 2014 Leapfrog Hospital Safety Score and the 2014 American Hospital Association to determine the association between Leapfrog Hospital Safety Score performance and three dimensions of organizational profitability: operating margin, net patient revenue, and operating income. RESULTS: Our findings suggest that improved hospital safety scores are associated with a relative risk of being in the top versus bottom quartile of financial performance: 5.41 times greater (p < .001) for operating margin, 10.98 times greater (p < .001) for net patient revenue, and 4.03 times greater (p < .001) for operating income. PRACTICE IMPLICATIONS: Our findings suggest that improved patient safety performance, as evaluated within the Leapfrog Hospital Safety Score, is associated with improved financial performance at the hospital level. Targeted focus on patient safety may allow hospitals to improve financial performance, maximize scarce resources, and generate additional capital to continue to positively evolve care.

Does Patient Safety Pay? Evaluating the Association Between Surgical Care Improvement Project Performance and Hospital Profitability.

EXECUTIVE SUMMARY: Financial issues are top concerns for hospital executives. Evolving reimbursement structures focused on value provide an incentive to fully understand how patient safety performance and financial outcomes are connected. To that end, this study examines the relationships between Surgical Care Improvement Project (SCIP) measurements and hospital financial performance.Using multinomial logistic regression, we determined the association between hospital patient safety performances via analysis of eight prophylaxis data elements drawn from the archived Hospital Compare data. The measures are SCIP-Inf-1 (prophylactic antibiotic prophylaxis received within 1 hr prior to surgical incision), SCIP-Inf-2 (prophylactic antibiotic selection for surgical patients), SCIP-Inf-3 (prophylactic antibiotics discontinued within 24 hr after surgery end time), SCIP-Inf-4 (cardiac surgery patients with controlled 6 A.M. postoperative serum glucose management), SCIP-Inf-9 (urinary catheter removal postsurgery), SCIP-Inf-Card-2 (beta-blocker during the perioperative period), and SCIP-Inf-VTE-2 (venous thromboembolism prophylaxis). Data from the American Hospital Association provided two dimensions of organizational profitability: operating margin and net patient revenue. Our results indicate that improved hospital safety performance is associated with a relative risk of higher operating margin and net patient revenue, with some variation noted among the measures of patient safety. Our findings suggest that targeted improvement in patient safety performance, as evaluated in the Hospital Compare data, is associated with improved financial performance at the hospital level. Increased attention to safe care delivery may allow hospitals to generate additional patent care earnings, improve margins, and create capital to advance hospital financial position.

Glucose-6-Phosphate Dehydrogenase Deficiency is Associated with Cardiovascular Disease in U.S. Military Centers.

Glucose-6-phosphate dehydrogenase (G6PD) protects erythrocytes from oxidative stress and hemolysis; G6PD deficiency is the most prevalent enzymopathy. The United States military routinely performs tests to prevent exposing G6PD-deficient personnel to antimalarial drugs that might cause life-threatening hemolytic reactions. In addition, G6PD is a key determinant of vascular function, and its deficiency can lead to impaired nitric oxide production and greater vascular oxidant stress-precursors to atherosclerosis and cardiovascular disease. Using military medical records, we performed a retrospective, cross-sectional study to investigate whether deficient G6PD levels are associated with a higher prevalence of cardiovascular disease than are normal levels, and, if so, whether the relationship is independent of accepted cardiovascular risk factors. We analyzed the medical records of 737 individuals who had deficient G6PD levels and 16,601 who had normal levels. Everyone had been screened at U.S. military medical centers from August 2004 through December 2007. We evaluated our dependent variable (composite cardiovascular disease) at the individual level, and performed binary logistic regression of our independent variable (G6PD status) and control variables (modifiable cardiovascular risk factors). The adjusted odds ratio of 1.396 (95% CI, 1.044-1.867; P <0.05) indicated that G6PD-deficient individuals have 39.6% greater odds of developing cardiovascular disease than do those with normal levels. Early intervention may reduce the incidence of cardiovascular disease in military personnel and civilians who have deficient G6DP levels.

Automated cell counts on CSF samples: A multicenter performance evaluation of the GloCyte system.

OBJECTIVES: Automated cell counters have replaced manual enumeration of cells in blood and most body fluids. However, due to the unreliability of automated methods at very low cell counts, most laboratories continue to perform labor-intensive manual counts on many or all cerebrospinal fluid (CSF) samples. This multicenter clinical trial investigated if the GloCyte System (Advanced Instruments, Norwood, MA), a recently FDA-approved automated cell counter, which concentrates and enumerates red blood cells (RBCs) and total nucleated cells (TNCs), is sufficiently accurate and precise at very low cell counts to replace all manual CSF counts. METHODS: The GloCyte System concentrates CSF and stains RBCs with fluorochrome-labeled antibodies and TNCs with nucleic acid dyes. RBCs and TNCs are then counted by digital image analysis. Residual adult and pediatric CSF samples obtained for clinical analysis at five different medical centers were used for the study. Cell counts were performed by the manual hemocytometer method and with the GloCyte System following the same protocol at all sites. The limits of the blank, detection, and quantitation, as well as precision and accuracy of the GloCyte, were determined. RESULTS: The GloCyte detected as few as 1 TNC/µL and 1 RBC/µL, and reliably counted as low as 3 TNCs/µL and 2 RBCs/µL. The total coefficient of variation was less than 20%. Comparison with cell counts obtained with a hemocytometer showed good correlation (>97%) between the GloCyte and the hemocytometer, including at very low cell counts. CONCLUSIONS: The GloCyte instrument is a precise, accurate, and stable system to obtain red cell and nucleated cell counts in CSF samples. It allows for the automated enumeration of even very low cell numbers, which is crucial for CSF analysis. These results suggest that GloCyte is an acceptable alternative to the manual method for all CSF samples, including those with normal cell counts.

Patterns of chronic inflammation in extensively treated patients with arachnoiditis and chronic intractable pain.

OBJECTIVE: To use biomarkers to gain insight into and gauge the residual (post-treatment) level of inflammation in two groups of intensively treated patients with severe chronic pain. METHODS: Three study groups were analyzed, and included: (i) patients (n = 90) with chronic intractable pain (CIP), (ii) patients (n = 26) with chronic pain and MRI-documented arachnoiditis (ARC) and (iii) normal subjects without a diagnosis of chronic pain (n = 86). We determined and compared the serum concentrations of Alpha-1 Antitrypsin (A1AT), Myeloperoxidase (MPO) and soluble Tumor Necrosis Factor receptor type 2 (sTNFR2) in each of the patient populations studied. RESULTS: Patients treated for ARC or CIP had higher serum levels of A1AT and MPO than normal untreated subjects without a diagnosis of chronic pain. ARC patients had an A1AT mean serum concentration of 167.9 ± 41.9 mg/dL as compared to 148.9 ± 35.2 mg/dL for normal subjects (p = 0.023). CIP patients had the highest mean serum A1AT level 183.6 ± 39.2 mg/dL with p values of <0.0001 or 0.08 when compared to normal subjects or ARC patients respectively. ARC patients had an MPO mean serum concentration of 344.6 ± 227.9 ng/mL as compared to 188.2 ± 107.5 ng/mL for normal subjects (p = < 0.0001). CIP patients had a similar mean serum MPO level of 352.3 ± 164 ng/mL with p values of <0.0001 or 0.85 when compared to normal subjects or ARC patients respectively. In addition, we noted a difference in the pattern of MPO expression in patients with ARC in that 34% had levels of MPO at normal or below and 31% had levels 2-fold or greater than normal. CONCLUSION: This data supports the concept that in centralized pain, sites of neuroinflammation elaborate MPO and other inflammatory factors which may not be completely cleared from the system despite extensive and complex treatment regimens.

Implications of early and guideline adherent physical therapy for low back pain on utilization and costs.

BACKGROUND: Initial management decisions following a new episode of low back pain (LBP) are thought to have profound implications for health care utilization and costs. The purpose of this study was to evaluate the impact of early and guideline adherent physical therapy for low back pain on utilization and costs within the Military Health System (MHS). METHODS: Patients presenting to a primary care setting with a new complaint of LBP from January 1, 2007 to December 31, 2009 were identified from the MHS Management Analysis and Reporting Tool. Descriptive statistics, utilization, and costs were examined on the basis of timing of referral to physical therapy and adherence to practice guidelines over a 2-year period. Utilization outcomes (advanced imaging, lumbar injections or surgery, and opioid use) were compared using adjusted odds ratios with 99% confidence intervals. Total LBP-related health care costs over the 2-year follow-up were compared using linear regression models. RESULTS: 753,450 eligible patients with a primary care visit for LBP between 18-60 years of age were considered. Physical therapy was utilized by 16.3% (n = 122,723) of patients, with 24.0% (n = 17,175) of those receiving early physical therapy that was adherent to recommendations for active treatment. Early referral to guideline adherent physical therapy was associated with significantly lower utilization for all outcomes and 60% lower total LBP-related costs. CONCLUSIONS: The potential for cost savings in the MHS from early guideline adherent physical therapy may be substantial. These results also extend the findings from similar studies in civilian settings by demonstrating an association between early guideline adherent care and utilization and costs in a single payer health system. Future research is necessary to examine which patients with LBP benefit early physical therapy and determine strategies for providing early guideline adherent care.

[Management of rectourethral fistulas with the York Mason procedure: surgical techniques and outcomes]. / Traitement des fistules uréthro-rectales par voie trans-anorectale de York Mason: technique et résultats.

OBJECTIVE: To report our experience for the management of urethro-rectal fistula by the York Mason technique. PATIENTS AND METHODS: We retrospectively analyzed the data of patients treated surgically for FUR by the technique of York Mason, between 2000 and 2012. RESULTS: Seventeen patients were included in the study. All patients had a bowel diversion before surgery. We observed four recurrences of FUR (23.5%). Recurrences occurred in a radiation field for two patients and in a oncologic recurrence for 1 patient. The fourth recurrence was treated by a second procedure of York Mason successfully. CONCLUSION: In our study, the York Mason technique was safe and reproducible for the treatment of FUR. The main factor of failure was a history of pelvic radiotherapy.

Is the ASVAB ST composite score a reliable predictor of first-attempt graduation for the U.S. Army operating room specialist course?

The U.S. Army Operating Room Specialist (68D) Course provides first class medical technician training to U.S. Army enlisted soldiers of the Army Medical Command. With a failure rate of approximately 12% over a 2-year period, this study was commissioned to determine whether the Armed Services Vocational Aptitude Battery (ASVAB) skilled technical (ST) Score served as a reliable predictor for successful first-attempt completion of the 68D course. A sample size of 373 was analyzed via a multivariate binary logistic regression model with 6 distinct independent variables. This study found that the ASVAB ST score, gender, and rank were predictors to first-attempt successful completion of the 68D training program. Specifically, students with an ST score 10 points higher than their peers were 5 times more likely to graduate. In addition, females were 2.5 times more likely to succeed than males and Army Privates (E2) were 3.2 times more likely than Privates (El). Specialists, Corporals (E4), Sergeants (E5), and Staff Sergeants (E6) combined, were 34 times more likely to succeed than Els. Although further study may be warranted, increasing the minimum ST score requirement in the admission guidelines and/or specific preventive assistance for lower-ranked students may decrease the first-attempt failure rate.

A multiscale microstructure model of carbon black distribution in rubber.

The increase of observations and computational capabilities favoured the numerical simulation of microstructure to derive the effective properties of materials. Indeed, the multiscale approaches, that use homogenization techniques, enable us to estimate or to give bounds of the overall properties of heterogeneous media. In this work, the objective is to develop a three-dimensional mathematical model of the morphology of the microstructure of rubber composite containing carbon black nano-fillers. This multiscale model consists of a combination of some primary models that correspond to the physical scales of the microstructure. It is identified according to an original method that uses statistical moments from experimental transmission electronic microscope (TEM) image data and from numerical TEM simulations. This method leads to three-dimensional representative simulations of microstructures that take the complex clustering effect of particles in aggregates, into account. Finally, the identified model of the morphology satisfies the experimental percolation rate of the carbon black aggregates in the material.

Fabrication of Ni nanostructures on p-Si by scanning probe lithography on Si3N4 films and selective electrodeposition.

Ni-Si nano Schottky junctions are fabricated by the combined process of scanning probe lithography and electrodeposition. The Si3N4 film was patterned by probe-induced oxidation and became a mask for selective electrodeposition of Ni on p-Si substrate. The Ni pattern consists of Ni nano dots, whose diameter is less then 60 nm. The composition and ferromagnetism of Ni dots are verified by energy dispersive spectrum and magnetic force microscopy. The schottky barrier of Ni-Si nano contact is 0.52 V determined by the I-V measurement of conducting atomic force microscopy (CAFM). From current mapping images, it shows that chemical impurity at the Ni-Si interfaces can result in the poor conductance of the junctions.

Local modification of self-assembled monolayers by a photocatalytic probe.

We demonstrate a novel nanolithography method based on the photocatalytic decomposition of the self-assembled monolayer (SAM) near a TiO2-coated probe. The TiO2 film was deposited on Ti-Pt coated Si probes by plasma sputtering. After annealing at 500 degrees C in air for 2 hr, the film was in the anatase phase, according to examination by Raman and X-ray diffraction spectra. Island-structured octadecyltrichlorosilane (OTS) partial monolayers on glass were used as the substrates. When the photocatalytic probe was illuminated by ultra-violet light, the modification occurred on the near OTS SAM islands. No change was observed on the exposed oxide surface between OTS islands. Without UV illumination, no modification occurred on OTS. Thus, the modification of the OTS surface is related to the photocatalytic reaction. A line width as small as 60 nm was achieved and observed by lateral force microscopy (LFM). The diffusion of reactive oxygen species were also observed from the remote photodecomposition of the OTS monolayer. These results should be beneficial to the development of hierarchically constructed nanolithography.

Speckle patterns with atomic and molecular de Broglie waves.

We have developed a nozzle source that delivers a continuous beam of atomic helium or molecular hydrogen having a high degree of transverse coherence and with adequate optical brightness to enable new kinds of experiments. Using this source we have measured single slit diffraction patterns and the first ever speckle-diffraction patterns using atomic and molecular de Broglie waves. Our results suggest fruitful application of coherent matter beams in dynamic scattering and diffractive imaging at short wavelength and with extreme surface sensitivity.

Probing the building blocks of eumelanins using scanning electron microscopy.

Scanning electron microscopy (SEM) is used to examine the structure of natural and synthetic melanins. Eumelanin from Sepia officinalis and synthetic eumelanin are found to be structurally dissimilar. The natural sample has a significant structural order with subunits that have a lateral dimension of approximately 15 nm. The synthetic samples, on the other hand, appear to be amorphous solids. These results lend support for the existence of fundamental structural units proposed from the analyses of wide-angle X-ray diffraction measurements and previous mass-spectrometry results. These findings also provide insight into the disparate photophysical behavior of Sepia and synthetic eumelanin.

Cytogenetic analysis of the bipotential murine pre-B cell lymphoma, P388, and its derivative macrophage-like tumor, P388D1, using SKY and CGH.

Spectral karyotyping (SKY) and comparative genomic hybridization (CGH) were used to elucidate the divergent cytogenetic make-up of the prototypical bilineage lymphoblastic pre-B lymphoma, P388, and its progenitor macrophage-like tumor, P388D1. P388 was found to be diploid and genomically stable. P388D1 was triploid, highly unstable and characterized by numerous marker chromosomes (Chrs) and composite rearrangements. The karyotype of P388D1 was so complex that its clonal relatedness to P388 would have remained questionable without confirmation by molecular analysis of the clonotypic immunoglobulin heavy-chain and light-chain gene recombinations that coexisted in both tumors. The intrinsic instability of the P388D1 genome was indicated by the observation that only four out of 42 aberrations uncovered by SKY (in a total of 27 metaphases) occurred consistently (100% incidence), whereas 27 changes occurred non-randomly (27 to 96% incidence) and 11 alterations randomly (4 to 11% incidence). Persistent cytogenetic instability was also observed in P388 'macrophages' after phorbol ester- and ionomycin-induced conversion in vitro of P388 lymphoma cells. The 'cytogenetic noise' in these cells was manifested by a multiplicity of sporadic chromosomal aberrations; ie 25 distinct changes were identified by SKY in 40 metaphases. The results in P388D1 and P388 'macrophages' were interpreted to indicate that the myeloid differentiation program in the bipotential pre-B cell lymphoma P388 is invariably characterized by karyotypic instability. The study presented here demonstrates the power of the combined SKY and CGH approach to resolve complicated karyotypes of important and widely used mouse tumors.

Wavelength-dependent photoacoustic calorimetry study of melanin.

Photoacoustic calorimetry is used to examine the energy dissipation in melanin under physiological conditions (pH 7.2) following irradiation by UV and visible (VIS) light. Four different excitation wavelengths were examined: 264 nm, representative of UVC radiation, 351 nm and 400 nm (UVA-I radiation) and 527 nm, representative of VIS radiation. Following absorption at 527 nm, essentially all of the photon energy is released nonradiatively on a sub-nanosecond of excitation. Similar results are observed at 400 nm. At 351 nm, most of the energy was released as heat; a small amount of energy was retained (5 +/- 5%). When melanin is excited at 264 nm, 29 +/- 7% of the photon energy is retained by the molecule for a time period longer than a few hundred nanoseconds. These results show that a long-lived excited state or reactive intermediate is generated upon UV irradiation, whereas all of the excitation energy is dissipated nonradiatively in the visible portion of the spectrum. These results establish that the photochemistry of melanin is wavelength dependent.