Hospitalist-led medicine emergency department team: associations with throughput, timeliness of patient care, and satisfaction.

BACKGROUND: Admitted patients boarding in the emergency department (ED) leads to hospital diversion. Active bed management and care for boarded patients can improve throughput. We developed a hospital medicine ED (HMED) team to participate in active bed management, and to care for boarded patients, to decrease diversion and improve throughput. METHODS: An HMED team was created to participate in active bed management and to care for boarded patients. The HMED team worked with the ED, nursing supervisors, and medical floors to manage inpatient beds. The primary outcome was percentage of hours of diversion attributed to lack of bed capacity. Secondary outcomes included the proportion of patients discharged within 8 hours of transfer to a medical floor, and the proportion of patients discharged from the ED. Promptness of clinical care was measured by rounding times. Satisfaction was obtained via survey. RESULTS: There was a relative reduction of diversion due to medicine bed capacity of 27% (4.5%-3.3%; P < 0.01), a relative reduction in the percentage of patients transferred to a medicine floor and discharged within 8 hours of 67% (1.5%-0.5%; P < 0.01), and a relative increase in the number of discharges from the ED of admitted medicine patients of 61% (4.9%-7.9%; P < 0.001). Boarded admitted patients were rounded upon 2 hours earlier (P < 0.0001) by the HMED team. Satisfaction with the HMED team was high. CONCLUSION: An HMED team can improve patient flow and decrease ED diversion while providing more timely care to patients boarded in the ED.

Severe Acute Local Reactions to a Hyaluronic Acid-derived Dermal Filler.

Injectable fillers are normally well tolerated by patients with little or no adverse effects. The most common side effects include swelling, redness, bruising, and pain at the injection site. This report describes three cases in which patients injected with a hyaluronic acid-derived injectable filler that is premixed with lidocaine developed adverse reactions including persistent swelling, pain, and nodule formation. Two of the three patients' abscesses were cultured for aerobic and anaerobic bacteria and mycobacterium. All three cultures were negative. Abscess persistence in all cases necessitated physical removal and/or enzymatic degradation with hyaluronidase. The effects subsided only after the product had been removed. Two of these patients were subsequently treated with other hyaluronic acid-derived dermal fillers without adverse events.

Fungal biodegradation of hard coal by a newly reported isolate, Neosartorya fischeri.

Cynodon dactylon (Bermuda grass) has been observed to grow sporadically on the surface of coal dumps in the Witbank coal mining area of South Africa. Root zone investigation indicated that a number of fungal species may be actively involved in the biodegradation of hard coal, thus enabling the survival of the plant, through mutualistic interaction, in this extreme environment. In an extensive screening program of over two thousand samples, the Deuteromycete, Neosartorya fischeri, was isolated and identified. The biodegradation of coal by N. fischeri was tested in flask studies and in a perfusion fixed-bed bioreactor used to simulate the coal dump environment. The performance of N. fischeri was compared to Phanaerochaete chrysosporium and Trametes (Polyporus) versicolor, previously described in coal biodegradation studies. Fourier transform infrared spectrometry and pyrolysis gas chromatography mass spectrometry of the biodegradation product indicated oxidation of the coal surface and nitration of the condensed aromatic structures of the coal macromolecule as possible reaction mechanisms in N. fischeri coal biodegradation. This is a first report of N. fischeri-mediated coal biodegradation and, in addition to possible applications in coal biotechnology, the findings may enable development of sustainable technologies in coal mine rehabilitation.

Six year audit of cardiac arrests and medical emergency team calls in an Australian outer metropolitan teaching hospital.

PROBLEM: In-hospital cardiac arrest often represents failure of optimal clinical care. The use of medical emergency teams to prevent such events is controversial. In-hospital cardiac arrests have been reduced in several single centre historical control studies, but the only randomised prospective study showed no such benefit. In our hospital an important problem was failure to call the medical emergency team or cardiac arrest team when, before in-hospital cardiac arrest, patients had fulfilled the criteria for calling the team. DESIGN: Single centre, prospective audit of cardiac arrests and data on use of the medical emergency team during 2000 to 2005. SETTING: 400 bed general outer suburban metropolitan teaching hospital. STRATEGIES FOR CHANGE: Three initiatives in the hospital to improve use of the medical emergency team: orientation programme for first year doctors, professional development course for medical registrars, and the evolving role of liaison intensive care unit nurses. KEY MEASURES FOR IMPROVEMENT: Incidence of cardiac arrests. EFFECTS OF THE CHANGE: Incidence of cardiac arrests decreased 24% per year, from 2.4/1000 admissions in 2000 to 0.66/1000 admissions in 2005. LESSONS LEARNT: Medical emergency teams can be efficacious when supported with a multidisciplinary, multifaceted education system for clinical staff.