Closing the Gap in Direct Admissions: A Quality Improvement Project.

BACKGROUND AND OBJECTIVES: Direct admissions (DAs) are nonemergent admissions to the inpatient unit that bypass the emergency department. Our institution lacked a standardized DA process, which resulted in postponement of prompt patient care. The purpose of the present study was to review and modify the existing DA process and to decrease the time between patient arrival for DA and placement of initial clinician orders. METHODS: A team was assembled and tasked with using quality improvement tools (eg, Define-Measure-Analyze-Improve-Control, fishbone diagrams, process mapping) to streamline the DA process to decrease average time between patient arrival for DA and initial clinician orders, from 84.4 minutes in July 2018 to 60 minutes or less by June 2019, without negatively affecting patient admission loyalty questionnaire scores. RESULTS: In a standardized and streamlined DA process, average time between patient arrival and provider order placement decreased to less than 60 minutes. This reduction was achieved without substantially affecting patient loyalty questionnaire scores. CONCLUSION: By using a quality improvement methodology, we developed a standardized DA process that resulted in prompt care for patients without decreasing admission loyalty scores.

Safety of chronic obstructive pulmonary disease patients undergoing carbon dioxide insufflation in extended endoscopic procedures.

INTRODUCTION: Carbon dioxide (CO2) insufflation for endoscopies has been shown to be more comfortable and safe, but only in patients without underlying chronic obstructive pulmonary disease (COPD). The aim of this study was to show that using CO2 is safe in COPD patients. METHODS: Patients were retrospectively identified who underwent extended endoscopic procedures during the time period of January 2012 to December 2017. Patients were included if they also had COPD. A matched control group without COPD was created during the same timeframe. All the patients were sedated with continuous monitoring of their CO2 levels by end-tidal CO2 (EtCO2). RESULTS: One hundred and ten patients had COPD and underwent an extended endoscopic procedure. These patients had a higher severity of their comorbidities (American Society of Anesthesiologists class 3 or 4) (93.6% [95% confidence interval [CI], 87.4%-96.9%] vs. 60.3% [95% CI, 51.1%-69.0%]; P < 0.01) and an increase of co-existing obstructive sleep apnea (33.6% vs. 6.3%, P < 0.01). There was no difference in baseline EtCO2, but the peak EtCO2 and postprocedure EtCO2 were both significantly higher in the COPD group. The only postprocedural complication found was an inability to be extubated immediately following the procedure with subsequent need to hospitalize the patient, which occurred in three patients (2.8%; 95% CI, 0.9%-7.9%) in the COPD group and one (0.9%; 95% CI, 0.2%-4.9%) in the non-COPD group (P = 0.37). CONCLUSION: The present study, which was the only study looking at CO2 insufflation specifically in COPD patients, provides evidence that CO2 insufflation is safe in COPD despite a slight increase in EtCO2.

Perfusion Tissue Culture Initiates Differential Remodeling of Internal Thoracic Arteries, Radial Arteries, and Saphenous Veins.

Adaptive remodeling processes are essential to the maintenance and viability of coronary artery bypass grafts where clinical outcomes depend strongly on the tissue source. In this investigation, we utilized an ex vivo perfusion bioreactor to culture porcine analogs of common human bypass grafts: the internal thoracic artery (ITA), the radial artery (RA), and the great saphenous vein (GSV), and then evaluated samples acutely (6 h) and chronically (7 days) under in situ or coronary-like perfusion conditions. Although morphologically similar, primary cells harvested from the ITA illustrated lower intimal and medial, but not adventitial, cell proliferation rates than those from the RA or GSV. Basal gene expression levels were similar in all vessels, with only COL3A1, SERPINE1, FN1, and TGFB1 being differentially expressed prior to culture; however, over half of all genes were affected nominally by the culturing process. When exposed to coronary-like conditions, RAs and GSVs experienced pathological remodeling not present in ITAs or when vessels were studied in situ. Many of the remodeling genes perturbed at 6 h were restored after 7 days (COL3A1, FN1, MMP2, and TIMP1) while others (SERPINE1, TGFB1, and VCAM1) were not. The findings elucidate the potential mechanisms of graft failure and highlight strategies to encourage healthy ex vivo pregraft conditioning.

Population structure of and mycotoxin production by Fusarium graminearum from maize in South Korea.

Fusarium graminearum (Gibberella zeae) is an important pathogen of wheat, maize, barley, and rice in South Korea, and harvested grain often is contaminated with trichothecenes such as deoxynivalenol and nivalenol. In this study, we examined 568 isolates of F. graminearum collected from maize at eight locations in South Korea. We used amplified fragment length polymorphisms (AFLPs) to identify four lineages (2, 3, 6, and 7); lineage 7 was the most common (75%), followed by lineage 6 (12%), lineage 3 (12%), and lineage 2 (1%). The genetic identity among populations was high (>0.98), and the effective migration rate between locations was higher than that between lineages. Female fertility varied by lineage: all lineage 7 isolates were fertile, while 70%, 26%, and 14% of the isolates in lineages 6, 3, and 2, respectively, were fertile. All lineage 3 and lineage 7 isolates produced deoxynivalenol, whereas most lineage 2 and 6 isolates produced nivalenol. Genotypic diversity in lineage 3 and lineage 6 populations is similar to that found in previously described Korean rice populations, but genotypic diversity in lineage 7 is much lower, even though similar levels of gene flow occur between lineage 7 populations. We conclude that lineage 7 was relatively recently introduced into South Korea, perhaps accompanying imported maize seeds.