Utilization and effects of mobile electronic clinical decision support on pediatric asthma care quality in the emergency department and inpatient setting.

OBJECTIVE: To determine utilization and impacts of a mobile electronic clinical decision support (mECDS) on pediatric asthma care quality in emergency department and inpatient settings. METHODS: We conducted an observational study of a mECDS tool that was deployed as part of a multi-dimensional, national quality improvement (QI) project focused on pediatric asthma. We quantified mECDS utilization using cumulative screen views over the study period in the city in which each participating site was located. We determined associations between mECDS utilization and pediatric asthma quality metrics using mixed-effect logistic regression models (adjusted for time, site characteristics, site-level QI project engagement, and patient characteristics). RESULTS: The tool was offered to clinicians at 75 sites and used on 286 devices; cumulative screen views were 4191. Children's hospitals and sites with greater QI project engagement had higher cumulative mECDS utilization. Cumulative mECDS utilization was associated with significantly reduced odds of hospital admission (OR: 0.95, 95% CI: 0.92-0.98) and higher odds of caregiver referral to smoking cessation resources (OR: 1.08, 95% CI: 1.01-1.16). DISCUSSION: We linked mECDS utilization to clinical outcomes using a national sample and controlling for important confounders (secular trends, patient case mix, and concomitant QI efforts). We found mECDS utilization was associated with improvements in multiple measures of pediatric asthma care quality. CONCLUSION: mECDS has the potential to overcome barriers to dissemination and improve care on a broad scale. Important areas of future work include improving mECDS uptake/utilization, linking clinicians' mECDS usage to clinical practice, and studying mECDS's impacts on other common pediatric conditions.

Implementing Pediatric Asthma Pathways in Community Hospitals: A National Qualitative Study.

BACKGROUND: Pathways can improve the quality of care and outcomes for children with asthma; however, we know little about how to successfully implement pathways across diverse hospital settings. Prior studies of pathways have focused on determining clinical effectiveness and the majority were conducted in children's hospitals. These approaches have left crucial gaps in our understanding of how to successfully implement pathways in community hospitals, where most of the children with asthma are treated nationally. OBJECTIVE: The aim of this study was to identify the key determinants of successful pediatric asthma pathway implementation in community hospitals. METHODS: We conducted a qualitative study of healthcare providers that served as project leaders in a national collaborative to improve pediatric asthma care. Data were collected by recording semi-structured discussions between project leaders and external facilitators (EF) from December 2017 to April 2018. Using inductive thematic analysis, we identified the themes that describe the key determinants of pathway implementation. RESULTS: Project leaders (n = 32) from 18 hospitals participated in this study. The key determinants of pathway implementation in community hospitals included (1) building an implementation infrastructure (eg, forming a team of local champions, modifying clinical workflows, delivering education/skills training), (2) engaging and motivating providers (eg, obtaining project buy-in, facilitating multidisciplinary collaboration, handling conflict), (3) addressing organizational and resource limitations (eg, support for electronic medical record integration), and (4) devising implementation solutions with EFs (eg, potential workflow modifications). CONCLUSIONS: Our identification of the key determinants of pathway implementation may help guide pediatric quality improvement efforts in community hospitals. EFs may play an important role in successfully implementing pathways in community settings.

Association of simian virus 40 vp1 with 70-kilodalton heat shock proteins and viral tumor antigens.

Proper folding of newly synthesized viral proteins in the cytoplasm is a prerequisite for the formation of infectious virions. The major capsid protein Vp1 of simian virus 40 forms a series of disulfide-linked intermediates during folding and capsid formation. In addition, we report here that Vp1 is associated with cellular chaperones (HSP70) and a cochaperone (Hsp40) which can be coimmunoprecipitated with Vp1. Studies in vitro demonstrated the ATP-dependent interaction of Vp1 and cellular chaperones. Interestingly, viral cochaperones LT and ST were essential for stable interaction of HSP70 with the core Vp1 pentamer Vp1 (22-303). LT and ST also coimmunoprecipitated with Vp1 in vivo. In addition to these identified (co)chaperones, stable, covalently modified forms of Vp1 were identified for a folding-defective double mutant, C49A-C87A, and may represent a "trapped" assembly intermediate. By a truncation of the carboxyl arm of Vp1 to prevent the Vp1 folding from proceeding beyond pentamers, we detected several apparently modified Vp1 species, some of which were absent in cells transfected with the folding-defective mutant DNA. These results suggest that transient covalent interactions with known or unknown cellular and viral proteins are important in the assembly process.