Process analysis to reduce MRI access time at a German University Hospital.

QUALITY PROBLEM OR ISSUE: Long access times for magnetic resonance imaging (MRI) can negatively impact the quality of care provided to patients. We investigated improving access by reducing MRI processing time. INITIAL ASSESSMENT: Data were collected for scans (n= 360) performed over 3 weeks (April-May 2008) at the University Hospital of Mannheim, Germany. Average access time, excluding emergencies, was 44 (±44) days for outpatients and 3 (±5) days for inpatients. Factors influencing total MRI processing time were identified using multivariate linear regression. In addition to region scanned, the total MRI processing time was significantly related to performing multiple scans (ß = 33.57, P< 0.01), using oral contrast media (ß = 13.58, P< 0.01), placing an intravenous (IV) catheter (ß = 5.00, P= 0.04) and scanning patients ≤8 years old (ß = 0.41, P= 0.03). Contrary to prior perceptions, emergency cases (5.6%) and late arrivals (12.8% >5 min late) were less than expected. CHOICE OF SOLUTION: Increasing scheduling flexibility to address non-modifiable process variation and completing preparatory activities outside the scanner room were identified as process improvement targets. IMPLEMENTATION: Scheduling was adapted to utilize three expected total MRI processing times and IV placement was moved outside the scanner room. EVALUATION: Planned hardware and software upgrades were completed concurrent to the process improvements. As a result, it was not possible to accurately measure the effect of implementing the scheduling and preparatory activity changes. LESSONS LEARNED: Clinical study team members' prior perceptions of workflow obstacles did not match the study findings. Utilizing insiders and outsiders during process analysis may limit bias in identification of process improvement opportunities.

Antioxidant responses of chickpea plants subjected to boron toxicity.

This study investigated oxidative stress and the antioxidant response to boron (B) of chickpea cultivars differing in their tolerance to drought. Three-week-old chickpea seedlings were subjected to 0.05 (control), 1.6 or 6.4 mm B in the form of boric acid (H(3)BO(3)) for 7 days. At the end of the treatment period, shoot length, dry weight, chlorophyll fluorescence, B concentration, malondialdehyte content and the antioxidant enzymes superoxide dismutase (SOD), peroxidase (POX), catalase (CAT), ascorbate peroxidase (APX) and glutathione reductase (GR) were measured. The 1.6 mm B treatment did not cause significant changes in shoot length of cultivars, although shoot length increased in the drought-tolerant Gökce and decreased in the drought-sensitive Küsmen after 6.4 mm B treatment. Dry weights of both cultivars decreased with 6.4 mm B treatment. Chlorophyll fluorescence (Fv/Fm) did not change in Gökce at either B level. Nor did it change in Küsmen with 1.6 mm B but Fv/Fm decreased with 6.4 mm B. Boron concentration in the shoots of both cultivars increased significantly with increasing levels of applied B. Significant increases in total SOD activity were observed in shoots of both cultivars given 1.6 and 6.4 mm B. Shoot extracts exhibited five activity bands, two of which were identified as MnSOD and Cu/ZnSOD. In comparison to the control group, all enzyme activities (except APX and SOD) decreased with 1.6 mm B stress. GR activity decreased, while activities of CAT, POX and APX did not change with 6.4 mm B in Küsmen. On the other hand, activities of CAT, APX and SOD increased in Gökce at both B levels. In addition, lipid peroxidation was higher in Küsmen than in Gökce, indicating more damage by B to membrane lipids in the former cultivar. These results suggest that (i) Gökce is tolerant and Küsmen is sensitive to B, and (ii) B tolerance of Gökce might be closely related to increased capacity of the antioxidative system (total SOD, CAT and APX) to scavenge reactive oxygen species and thus suppress lipid peroxidation under B stress. To the best of our knowledge, this is the first report on the antioxidant response of chickpea seedlings to B toxicity.