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OBJECTIVES Initiation and continuation of empirical antimicrobial agents for a 48–72-hour observation period is routine practice in the diagnosis and treatment of infants and children with concern for bacteremia. We examined blood cultures at a freestanding pediatric hospital over a 6-year period to determine the time to positivity. METHODS Data were extracted for all patients who were hospitalized and had blood cultures drawn between January 2013 and December 2018. Time to positivity was calculated on the basis of date and time culture was collected compared with date and time growth was first reported. RESULTS Over a 6-year period, 89 663 blood cultures were obtained, of which 6184 had positive results. After exclusions, a total of 2121 positive blood culture results remained, including 1454 (69%) pathogens and 667 contaminants (31%). For all positive blood culture results, the number and percentage positive at 24, 36, and 48 hours were 1441 of 2121 (68%), 1845 of 2121 (87%) and 1970 of 2121 (93%), respectively. One hundred twenty-five (66 pathogens, 59 contaminants) of the 89 663 cultures (0.14%) yielded positive results between 36 and 48 hours, indicating that 719 patients would need to be treated for 48 hours rather than 36 hours to prevent 1 case of antibiotic termination before positive result. Median times to positive result by pathogen and service line are presented. CONCLUSIONS This study reveals that ≤36 hours may be a sufficient period of observation for infants and children started on empirical antimicrobial agents for concern for bacteremia. These findings highlight opportunities for antimicrobial stewardship to limit antimicrobial .

Highlights • The National Marrow Donor Program (NMDP) received preliminary search requests for over 3300 domestic and 3700 international allogeneic hematopoietic cell transplant candidates during the initial phase of the coronavirus disease 2019 (COVID-19) pandemic. • Despite a decrease in preliminary search requests, the number of unrelated donor grafts infused at domestic transplant centers following the initial phase of COVID-19 was only 4% less than the same period of time 1 year earlier. • Of over 2800 transportation legs and over 1600 transports completed through the NMDP, only 1 product was delivered outside of the requested time window in the initial period after COVID-19., The impact of the coronavirus disease 2019 (COVID-19) pandemic on hematopoietic cell transplant (HCT) donor registries and transplant center (TC) practices is underreported. This article reports on the National Marrow Donor Program (NMDP) Be The Match Registry and its coordinating the provision of unrelated donor (URD) products to domestic and international TCs during the initial 3 months of the COVID-19 pandemic (March through May 2020). Specifically, NMDP data are presented for disease indications for transplant, URD search volumes and availability, graft requests and processing, courier utilization and performance, and conversion rates from formal donor search and workup to graft collection and shipment. Data following the onset of COVID-19 are compared to the immediate 3 months prior to the COVID-19 pandemic (December 2019 through February 2020) and the same quarter 1 year prior to COVID-19 (March through May 2019). During the initial onset of COVID-19 and compared to 1 year prior, TCs requested and the NMDP performed less donor searches. More multiple URD and direct to workup requests were processed by the NMDP, which likely reflected reductions in donor availability. Yet TCs continued to perform allogeneic transplants for acute disease indications like acute leukemia and myelodysplasia, using more cryopreserved grafts than before COVID-19. In comparison to prepandemic patient cycle conversion rates and durations, the NMDP was able to convert patient cycles at nearly the same or higher rates and in similar or shorter periods of time. Last, despite significant challenges caused by the pandemic, including interruptions in domestic courier services and travel restrictions, graft products were delivered to and received by TCs in similar periods of time than before COVID-19. Taken together, these data show that NMDP service line operations continued to function effectively during the early phases of the COVID-19 pandemic, ensuring requests for and delivery of URD products to domestic and international allogeneic HCT recipients.

SUMMARY The primary drivers for service line development have historically been market differentiation and profitable growth. In the current transition to value-based care, however, several other factors are now driving service line strategy. Specifically, in a value-based world, service lines must be patient centric, not provider centric; they must focus on more than hospitals; and they must be market facing.To build the operating model of the future and succeed in a value-based world, health systems need to reimagine the clinical, operational, and financial features of today's service lines. In working toward this future state, a coordinated, evidence-based care model with a multidisciplinary care team must replace today's episodic care. Easy access to prompt solutions and a seamless, low-stress experience for both patients and providers will be new competitive differentiators, along with cost transparency. Outcomes, patient convenience, and the total cost of care will drive future service line relationships between health systems and physicians. The criteria for selecting physician partners will be materially different, too.In implementing this future-state model, healthcare organizations will need to reconcile several opposing forces and tear down structural and operational silos. Health systems that can navigate through these challenges can realize numerous benefits.

As the access of radiology practices to dual-energy CT (DECT) has increased worldwide, seamless integration into clinical workflows and optimized use of this technology are desirable. In this article, we provide basic concepts of commercially available DECT hardware implementations, discuss financial and logistical aspects, provide tips for protocol building and image routing strategies, and review radiation dose considerations to establish a DECT service line in abdominal imaging. KEY POINTS: • Tube-based and detector-based DECT implementations with varying features and strengths are available on the imaging market. • Thorough assessment of financial and logistical aspects is key to successful implementation of a DECT service line. • Optimized protocol building and image routing strategies are of critical importance for effective use and seamless inception of DECT in routine clinical workflows.

BACKGROUND: Excess days in acute care (EDAC) after total joint arthroplasty (TJA) represent a large economic burden. We developed an Orthopedic EDAC program that triages TJA patients to the appropriate service line (orthopedic vs medicine) and level of care (observation vs inpatient) on re-presentation. We developed and used evidence-based protocols for the treatment of TJA patients who are rehospitalized. METHODS: We defined Orthopedic EDAC as the length of stay (LOS) during readmission and observation stays. Our target population included TJA and revision TJA patients. Patients between April 2016 and September 2017 and between October 2017 and September 2018 were defined as pre-implementation and postimplementation of the Orthopedic EDAC program, respectively. RESULTS: A total of 2,662 patients underwent TJA and revision TJA during the pre-implementation and postimplementation periods. Twenty-three patients were managed on observation status during the study period. Readmissions decreased from 49 (6.1%) during preimplementation to 37 (2.0%) during post-implementation (P = .004). By design, more rehospitalized patients were on the orthopedic surgery service after implementation of the Orthopedic EDAC program (n = 49; 70%) versus before (n = 22; 35%; P = .028). EDAC LOS decreased from 7.75 days to 4.73 days (P = .005). CONCLUSION: In this single-center, before-after pilot of a novel Orthopedic EDAC program, we demonstrated a reduction in readmissions and Orthopedic EDAC LOS, as well as improved continuity of care for TJA patients on representation. Journal of Hospital Medicine 2020;15:XXXXXX. © 2020 Society of Hospital Medicine

OBJECTIVES Study objectives were to: 1) explore how nursing care quality data (NCQD) was understood and interpreted; and 2) identify, compare, and contrast individual and group responses. BACKGROUND Little evidence exists on how to best disseminate NCQD information. This study explores the outcomes of implementing an NCQD and human-interest information slide show across an inpatient surgery nursing service line using electronic screens. METHODS Methods included semistructured interviews, qualitative analysis, and diagramming. RESULTS The human-interest content most often attracted viewers' attention, but they were also exposed to NCQD. Interpretations and understandings differed among groups and between individuals. Among staff members, the human-interest content facilitated team-building, whereas NCQD provided meaningful recognition. Nursing care quality data evidenced the efforts that were being made to improve and provide excellent patient care. CONCLUSIONS Using innovative dissemination methods can enhance understanding of NCQD among clinical providers. Creating microclimates of change and innovation within complex healthcare environments can benefit staff members and patients.

SUMMARY STATEMENT Changing healthcare systems and efforts to decrease medical costs have resulted in many more patients and caregivers (PCs) needing to manage life-sustaining therapies on their own. Given the potential for underpreparedness to result in increased morbidity and mortality, developing safe and efficient homecare training methods for PCs is essential. Medical simulation with PCs is an underused tool, which has the potential to decrease anxiety and increase preparedness through opportunities for repeated practice of medical procedures within a safe, controlled environment. This article describes the development of a hospital-based simulation service line for PCs, leveraging lessons learned from training for 250 patients and 450 caregivers in 14 different departments and subspecialties, and explains adaptations of standard simulation methods necessary for safe and effective use of simulation with this unique population. Process blueprint, examples of specific programs, as well as feedback from participants and clinicians are included.

Background The mortality index, or the ratio of observed to expected mortality, is a reported quality metric that has been assumed to directly reflect patient care. However, documentation and coding that does not use knowledge of how a reported mortality index is derived could reflect poorly on a hospital or service line. We present our effort at reducing the reported mortality index of neurosurgery and neurology patients within a neurocritical care unit through documentation and coding accuracy with direct incorporation of mortality modeling. Methods Using a reported method from Vizient Inc., we generated a spreadsheet tool to enable direct manipulation of the data to identify documentation and coding issues that influenced the reported mortality index in a retrospective set of patients. Subsequently, we implemented the prospective changes to documentation and coding and compared our calculated mortality index to the reported Vizient mortality index. Results Prospective implementation of the documentation and coding issues identified through our spreadsheet tool resulted in a drastic reduction of both our calculated and the reported Vizient mortality index. Conclusions Incorporating knowledge of mortality index modeling into the documentation and coding resulted in impressive reductions in the reported mortality index for our patients, serving as a both an internal benchmark and a method of comparison with other institutions.

The economic burden of health care in the United States continues to rise with no sign of letting up. The shift to value-based reimbursement offers a potential solution to maximize the outcome by pegging health care reimbursement to the quality of care provided. The service line concept of gastrointestinal disorders incorporates a multidisciplinary treatment model and maximizes the efficiency of patient-care giver encounters. The concept and implementation of a service line approach in endoscopy operation remain largely nascent even among large health care institutions. This article submits a multidisciplinary endoscopy operation model implemented in the author's institution as a suggestion.

Antibiotics are widely used in neonatal intensive care units (NICUs). We conducted a cross-sectional analysis of antibiotic use across US NICUs to evaluate overall, broad-spectrum, and combination antibiotic use. Patterns of antibiotic use varied by medical versus surgical service line, hospital, and geographic location.

Objective The Recruitment Innovation Center (RIC), partnering with the Trial Innovation Network and institutions in the National Institutes of Health-sponsored Clinical and Translational Science Awards (CTSA) Program, aimed to develop a service line to retrieve study population estimates from electronic health record (EHR) systems for use in selecting enrollment sites for multicenter clinical trials. Our goal was to create and field-test a low burden, low tech, and high-yield method. Materials and Methods In building this service line, the RIC strove to complement, rather than replace, CTSA hubs’ existing cohort assessment tools. For each new EHR cohort request, we work with the investigator to develop a computable phenotype algorithm that targets the desired population. CTSA hubs run the phenotype query and return results using a standardized survey. We provide a comprehensive report to the investigator to assist in study site selection. Results From 2017 to 2020, the RIC developed and socialized 36 phenotype-dependent cohort requests on behalf of investigators. The average response rate to these requests was 73%. Discussion Achieving enrollment goals in a multicenter clinical trial requires that researchers identify study sites that will provide sufficient enrollment. The fast and flexible method the RIC has developed, with CTSA feedback, allows hubs to query their EHR using a generalizable, vetted phenotype algorithm to produce reliable counts of potentially eligible study participants. Conclusion The RIC’s EHR cohort assessment process for evaluating sites for multicenter trials has been shown to be efficient and helpful. The model may be replicated for use by other programs.

Introduction: As of 2013, the all-cause readmission rate among Medicare fee-for-service beneficiaries was 17.5%. In addition to poor outcomes, 30-day hospital readmissions account for over $17 billion in Medicare expenditures. The presence and involvement of a primary care provider can be essential during the transition period from hospital discharge to the outpatient setting. Objective: In an effort to reduce 30-day hospital readmissions a transitional care management (TCM) service was implemented in a multi-site family medicine practice. Methods: The transitional care service line was structured after the 2013 Centers for Medicare & Medicaid Services recommended process for transitioning patients from an inpatient to an outpatient setting. The service included a care team RN, electronic documentation in an electronic medical record and the primary care physician. Results: The 30-day readmission rate was 12.0% in the 10 months before implementation of the new service line and 12.4% in the first 10 months after implementation of the new service line. There was no evidence of an impact of the new service line on a decline in 30-day readmission rates (P = .18). Discussion: Hospital readmissions generate unnecessary costs and often present a major burden on patients and their families. Early engagement with patients after hospital discharge will help to address any acute needs, verify medication adherence and ensure that necessary equipment and services are available. Conclusion: Although there was no evidence of an impact of the new service line on a decline in 30-day readmission rates it was decided that this service was a benefit to the patients and the physicians involved.

Aims Revision total knee arthroplasty (rTKA) accounts for approximately 5% to 10% of all TKAs. Although the complexity of these procedures is well recognized, few investigators have evaluated the cost and value-added with the implementation of a dedicated revision arthroplasty service. The aim of the present study is to compare and contrast surgeon productivity in several differing models of activity. Materials and Methods All patients that underwent primary or revision TKA from January 2016 to June 2018 were included as the primary source of data. All rTKA patients were categorized by the number of components revised (e.g. liner exchange, two or more components). Three models were used to assess the potential surgical productivity of a dedicated rTKA service : 1) work relative value unit (RVU) versus mean surgical time; 2) primary TKA with a single operating theatre (OT) versus rTKA with a single OT; and 3) primary TKA with two OTs versus rTKA with a single OT. Results In total, 4570 procedures were performed: 4128 primary TKAs, 51 TKA liner exchanges, and 391 full rTKAs. Surgical time was significantly different between the primary TKA, liner exchange, and rTKA cohorts (100.6, 97.1, and 141.7 minutes, respectively; p < 0.001). Primary TKA yielded a mean of 7.1% more RVU/min per procedure than rTKA. Our one-OT model demonstrated that primary TKA (n = 4) had a 1.9% RVU/day advantage over rTKA (n = 3). If two OTs are used for primary TKA (n = 6), the outcome strongly favours primary TKA by an added 34.6% RVUs/day. Conclusion Our results suggest that a dedicated rTKA service would lead to lower surgeon remuneration based on the current RVU paradigm. Revision arthroplasty specialists may need additional or alternative incentives to promote the development of a dedicated revision service. Through such an approach, healthcare organizations could enhance the quality of care provided, but surgeon productivity measures would need to be adjusted to reflect the burden of these cases. Cite this article: Bone Joint J 2019;101-B:675–681.

Background Cardiovascular electronic consultation is a new service line in consultative medicine and enables care without in-person office visits. We aimed to evaluate accessibility and time saved as measures of efficiency, determine the safety of cardiology electronic consultations, and assess satisfaction by responding cardiologists. Methods Using a mixed-methods approach and a modified time-driven, activity-based, costing framework, we retrospectively analysed cardiology electronic consultations. A random subset of 500 electronic consultations referred between 2013–2017 were reviewed. Accessibility was determined based upon increased number of patients served without the need for an in-person clinic visit. To assess safety, medical records were reviewed for emergency room visits or hospital admission at six months from the initial electronic consultation date. Responding cardiologist satisfaction was assessed by voluntary completion of an online survey. Results The majority of electronic consultations were related to medication advice, clearance for surgery, evaluation of images, or guidance after abnormal testing. Recommendations included echo (10.8%), stress testing (5.0%), other imaging (4.0%) and other subspecialist referrals (3.8%). Electronic consultations were completed within 0.7±0.5 days of the request, with a time to completion of 5–30 min. Over a six-month follow-up, 13.9% of patients had an in-person visit and 2.2% of patients were hospitalised, but none were directly related to the electronic consultation question. Satisfaction by responding cardiologists was modest. Conclusion In conclusion, within a single-payer system, cardiology electronic consultations represent a convenient and safe alternative for providing consultative cardiovascular care, but further optimization is necessary to minimise electronic consultation fatigue experienced by cardiologists.

The coronavirus disease 2019 (COVID-19) pandemic has become the dominant health-care issue of this generation and has reached every corner of the health-care delivery spectrum. Our 3 orthopaedic departments enacted a response to the COVID-19 pandemic within our organizations. We discuss our health-care systems’ response to the outbreak and offer discussion for the recovery of the orthopaedic service line within large health-care systems.

Introduction The COVID‐19 pandemic caused by the severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2) virus has altered the health care environment for the management of head and neck cancers. The purpose of these guidelines is to provide direction during the pandemic for rational Head and Neck Cancer management in order to achieve a medically and ethically appropriate balance of risks and benefits. Methods Creation of consensus document. Results The process yielded a consensus statement among a wide range of practitioners involved in the management of patients with head and neck cancer in a multihospital tertiary care health system. Conclusions These guidelines support an ethical approach for the management of head and neck cancers during the COVID‐19 epidemic consistent with both the local standard of care as well as the head and neck oncological literature.

Objective This study examined the impact of centralized and decentralized unit designs on an interdisciplinary team's perceptions of efficiency through the use of a preoccupancy and postoccupancy evaluation of a cardiovascular unit. Background During the premove study, the service line was housed across 4 separate locations, each with a centralized nurses' station. The postmove design was housed on 1 floor with decentralized stations. Methods For this qualitative study, 14 focus groups and 1 interview were conducted. Analysis of the data was guided by a developed framework for efficiency classified into 7 categories. Results Outcomes reveal that efficiency was impacted by issues including walking, access to supplies and equipment, proximity to staff, and overall unit configuration and size. Conclusions Although the design of the decentralized unit positions staff members closer to patients, many feel isolated while the centralized units seemed to better promote staff proximity and access to supplies.

Diffusing innovation and best practices in healthcare are among the most challenging aspects of advancing patient safety and quality improvement. Recommendations from the Baldrige Foundation, Institute for Healthcare Improvement, and The Joint Commission provide guidance on the principles for successful diffusion. Perioperative leaders are encouraged to applying these principles to high priority areas such as handovers, enhanced recovery and patient blood management. Completing a successful pilot project can be exciting, however, effective diffusion is essential to achieving meaningful and lasting impact on the service line and health system.

The original architects of Medicare modeled the payment system on the existing fee-for-service (FFS) structure that historically dominated the health-insurance market. Under the FFS paradigm, health-care expenditures experienced an exponential rise. In response, the managed care and capitation models of health-care delivery were developed. However, changes in Medicare reimbursement, along with an increasing volume of orthopaedic procedures and escalating implant costs, call into question the cost-effectiveness of this service line. The success of the Medicare Acute Care Episode (ACE) Demonstration Project proved the feasibility of value-based care and ushered in a new era of bundled payment initiatives.

Experimental and preclinical evidence suggest that adoptive transfer of regulatory T (Treg) cells could be an appropriate therapeutic strategy to induce tolerance and improve graft survival in transplanted patients. The University of Kentucky Transplant Service Line is developing a novel phase I/II clinical trial with ex vivo expanded autologous Treg cells as an adoptive cellular therapy in renal transplant recipients who are using everolimus (EVR)-based immunosuppressive regimen.The aim of this study was to determine the mechanisms of action and efficacy of EVR for the development of functionally competent Treg cell-based adoptive immunotherapy in transplantation to integrate a common EVR-based regimen in vivo (in the patient) and ex vivo (in the expansion of autologous Treg cells). CD25 Treg cells were selected from leukapheresis product with a GMP-compliant cell separation system and placed in 5-day (short) or 21-day (long) culture with EVR or rapamycin (RAPA). Multi-parametric flow cytometry analyses were used to monitor the expansion rates, phenotype, autophagic flux, and suppressor function of the cells. phosphoinositide 3-kinase/protein kinase B/mammalian target of rapamycin signaling pathway profiles of treated cells were analyzed by Western blot and cell bioenergetic parameters by extracellular flux analysis.EVR-treated cells showed temporary slower growth, lower metabolic rates, and reduced phosphorylation of protein kinase B compared with RAPA-treated cells. In spite of these differences, the expansion rates, phenotype, and suppressor function of long-term Treg cells in culture with EVR were similar to those with RAPA.Our results support the feasibility of EVR to expand functionally competent Treg cells for their clinical use.

Interventional radiologists' involvement in pain service lines continues to increase. While clinical and technical acumen is an obvious prerequisite, understanding the coding related to these procedures is also a must. The pain specialist's practice is largely outpatient based, therefore, the coding and subsequent billing for outpatient clinic visits may be an important revenue generator. A brief review of the evaluation and management (E&M) coding, as well as review of procedural CPT coding for pain interventions is discussed herein. While not overly difficult, there are certain nuances regarding the coding and reporting of these procedures. Developing an understanding of the proper use of CPT coding involved in pain procedures will allow the interventionalist to accurately capture the work performed and further support a pain service line. Case examples are used to reinforce certain points.

Oncology research protocol design has become increasingly complex. Investigational medications used in chemotherapy, both i.v. and oral agents, are being used in conjunction with standard-of-care treatment regimens. In addition, treatments often occur over multiple clinic or hospital visits. The

In February of 2016, the City of Flint, Michigan commenced the FAST start initiative with the aim “to get the lead out of Flint” by replacing lead and galvanized steel service lines throughout the city. An estimated 29,100 parcels are scheduled for service line replacement (SLR) at an expected cost of $172 million. The lead exposure benefits of SLR are evaluated by analyzing Sentinel data on hundreds of repeatedly sampled homes in Flint from February 16, 2016 to July 21, 2017, comparing water lead (WL) in homes with and without lead service lines. Samples taken from homes with lead service lines were significantly more likely to exceed specified thresholds of WL than homes without lead service lines. Second, regardless of service line material type, sampled homes experienced significant reductions in WL with elapsed time from Flint’s switchback to water provided by the Detroit Water and Sewage Department. Third, the risk of exceedance of WL > 15 μg/L was uncorrelated with service line material type. These results are robust to sample restrictions, period stratification, time operations, reference group definitions, and statistical modeling procedures. On the question of what is gained from SLR over optimal corrosion control techniques, we simulated age-specific lead uptake (μg/day) and blood lead levels (μg/dL) for children in Flint at 16 and 90 weeks of elapsed time from Flint’s switchback to Detroit water. At 90 weeks from the switchback in water source, the quantity of water lead consumed by children in homes with lead service lines decreased 93%, as compared to 16 weeks. Lead exposure benefits of SLR have declined in time, with modest differences in lead uptake across homes with different service lines. In light of results, policy considerations for Flint and nationwide are discussed.

Eliminating the sources of human lead exposure is an ongoing public health goal. Identifying the make-up of household plumbing and service line material type is important for many reasons including understanding lead release sources and mechanisms, targeting locations for lead service line (LSL) removal, and assessing the effectiveness of lead remediation strategies. As part of the response to Flint, Michigan's drinking water lead public health crisis, a return to their original drinking water source (Lake Huron) and an increase in orthophosphate dose was implemented in late 2015. In 2016, EPA performed multiple rounds of sequential or “profiling” water sampling to evaluate corrosion control effectiveness and identify lead sources in homes and service lines, as well as to evaluate the effectiveness of corrosion control treatment with time on the different plumbing components. The results showed that lead levels, including high lead levels likely associated with particles, decreased with time in homes sampled during the 11-month evaluation period. Although sequential sampling indicated that brass fittings, brass fixtures, and galvanized pipes were lead sources, LSLs were the greatest source of lead when present. Following the removal of LSLs, the total mass of lead contributed to the drinking water decreased by 86% on average.

Aims Transvenous lead extraction is challenging, often requiring specialist equipment and prolonged hospital admission. A single tariff or itemized costs may be available for reimbursement. Due to limited data relating to the costs of transvenous extraction, it is unclear whether either form of reimbursement is adequate. We aim to describe accurately the total real-world costs of managing patients undergoing transvenous extraction at a single, large centre. We further aim to consider the additional costs of device reimplantation. Methods and results At a single UK extraction centre, a retrospective, patient level service line analysis was undertaken, during a complete financial year. Seventy-four patients required transvenous extraction (47 infected and 27 non-infected; 156 leads). Sixty-nine procedures (93%) were performed under general anaesthesia, with a median time in theatre of 95 min [interquartile range (IQR) 71-120]. Specialist extraction tools were required for 130 leads (83%). The median hospitalization duration was 3 days (IQR 1-8). The mean cost of extraction was £9228 (±4099); infected £10 727 (±4178) and non-infected £6619 (±2269). With the additional costs of device reimplantation, the overall mean cost rose to £17 574 (±12 882); infected £22 615 (±13 343) and non-infected £8801 (±5007). At the time of this study, the UK NHS tariff was £2530 for elective and £4764 for non-elective extraction, covering barely half of the real costs. Conclusion We demonstrated a substantial difference between the real-world cost of extraction and the UK NHS tariff. Extracting centres should scrutinize their practice, including the timing of reimplantation.

Profile, regulatory, and investigative sampling were completed in six utilities to study the impact of partial and full lead service line replacements (LSLRs) on water lead levels (WLLs) and consumer's exposure. As compared to households with no replacement, lead release after partial LSLR (PLSLR) was generally greater in the short term (3-50 days), and comparable or lower in the medium (2 years) and long-term (2 years). This was mainly explained by insufficient time elapsed to stabilize scales after disturbances to the service line. One utility showed sustained lead release over 18 months after PLSLR. Moreover, the reduction in WLLs was small when analyzing results for the same households. As a comparison, full LSLR decreased WLLs drastically and immediately. The occurrence of low (0-5 μg/L) to high (≥50 μg/L) WLLs in the profiles varied between households and reflected the variability of exposure among households in the same system. Using this probability of occurrence, the distribution of WLLs of exposure was estimated for households with or without a PLSLR, and used to model young children blood lead levels (BLLs) for both groups of households. The range of modeled BLLs decreased slightly for households with PLSLR, but still overlapped the range estimated for households with no replacement. This analysis suggests that, in a system, PLSLRs do not reduce young children blood lead levels except in a fraction of households.

Our group began performing erbium-YAG 2940 wavelength fractional resurfacing of burn scar in our burn center's dedicated burn operating room (OR) in January 2016. The impact of these procedures on the performance of a mature, dedicated burn OR is unknown. All burn OR cases performed between January 1, 2015 and December 31, 2015 served as a pre-laser (PRE-LSR) historical control. A postintervention cohort of laser-only cases (LSR) performed between January 1, 2016 and August 17, 2016 was then identified. PRE-LSR and LSR cases were retrospectively reviewed for OR component times, and work relative value units (wRVU) billed. A total of 628 burn OR cases were done in 2015 (PRE-LSR), while 488 burn OR cases were done between January 1 and August 17, 2016. Of these 488, 59 cases were LSR (12.1%). Calculated on a monthly basis, significantly more cases were done per day in the LSR era (2.2 ± 0.4 cases/d) than PRE-LSR (1.6 ± 2.0 cases/d; P < .0001). The LSR group was significantly shorter than the PRE-LSR group for all OR component times (induction, prep, and procedure all P < .0001; transport out, P = .01; room turnover, P = .004). Aggregate OR component time was 79.2 ± 33.4 minutes for LSR and 157.5 ± 65.0 minutes for PRE-LSR (P < .0001). LSR yielded 6.9 ± 3.2 wRVU/h, while PRE-LSR generated 12.2 ± 8.9 wRVU/h (P < .0001). Despite significantly shorter OR component times and more cases being done per day, laser treatment of burn scar using a single 17108 Current Procedural Terminology code cuts wRVUs generated per hour in a mature burn OR roughly in half.

Legacy lead and copper components are ubiquitous in plumbing of large buildings including schools that serve children most vulnerable to lead exposure. Lead and copper samples must be collected after varying stagnation times and interpreted in reference to different thresholds. A total of 130 outlets (fountains, bathroom and kitchen taps) were sampled for dissolved and particulate lead as well as copper. Sampling was conducted at 8 schools and 3 institutional (non-residential) buildings served by municipal water of varying corrosivity, with and without corrosion control (CC), and without a lead service line. Samples included first draw following overnight stagnation (8h), partial (30 s) and fully (5 min) flushed, and first draw after 30 min of stagnation. Total lead concentrations in first draw samples after overnight stagnation varied widely from 0.07 to 19.9 μg Pb/L (median: 1.7 μg Pb/L) for large buildings served with non-corrosive water. Higher concentrations were observed in schools with corrosive water without CC (0.9-201 μg Pb/L, median: 14.3 μg Pb/L), while levels in schools with CC ranged from 0.2 to 45.1 μg Pb/L (median: 2.1 μg Pb/L). Partial flushing (30 s) and full flushing (5 min) reduced concentrations by 88% and 92% respectively for corrosive waters without CC. Lead concentrations were10 μg Pb/L in all samples following 5 min of flushing. However, after only 30 min of stagnation, first draw concentrations increased back to45% than values in 1st draw samples collected after overnight stagnation. Concentrations of particulate Pb varied widely (≥0.02-846 μg Pb/L) and was found to be the cause of very high total Pb concentrations in the 2% of samples exceeding 50 μg Pb/L. Pb levels across outlets within the same building varied widely (up to 1000X) especially in corrosive water (0.85-851 μg Pb/L after 30MS) confirming the need to sample at each outlet to identify high risk taps. Based on the much higher concentrations observed in first draw samples, even after a short stagnation, the first 250mL should be discarded unless no sources of lead are present. Results question the cost-benefit of daily or weekly flushing as a remediation strategy. As such, current regulatory requirements may fail to protect children as they may not identify problematic taps and effective mitigation measures.

The primary objectives of this study were to identify patient and community benefits of mandatory intensivist management in a neurocritical care (NCC) unit. Our hospital recently mandated intensivist management for patients admitted to the NCC unit. As one of the only comprehensive stroke centers in Orlando, an unacceptably high number of patients were being denied admission because of overcapacity. We compared length of stay (LOS), complications, outcomes, total admissions, and emergency transfer center closure rates before and after implementation of mandatory intensivist management. A retrospective review comparing 1551 patients admitted to a 20 bed NCC unit from November 1, 2009 to October 31, 2010 (prior to mandatory intensivist management) with 1702 patients admitted from January 1, 2011 to December 31, 2011 (after the requirement) was performed. This included examining LOS, Acute Physiology and Chronic Health Evaluation III (APACHE) scores, service line closure rates, and mortality during both time periods. Analysis revealed that despite comparable APACHE scores, implementation of mandatory intensivist management reduced overall NCC LOS, 4.6 versus 3.7 days, (p

Background: Traditional senior practicum experiences (SPEs) are microsystem based—they allow senior nursing students the opportunity to build professional nursing competencies as they transition into practice. As health care transformation continues unabated, there is a need to work toward closing the gap between nursing academia and nursing practice. Method: A cardiovascular service line created an innovative SPE to better prepare senior nursing students for working as professional nurses in a service line model. Results: The Senior Practicum Immersion Experience (SPIE) proved to be beneficial to senior practicum students and offered firsthand experience of the role professional nurses play in a service line model. This model increased the number of senior practicum students accepted into the cardiac service line by 50%. Conclusion: The SPIE creates an innovative solution to increasing the number of senior practicum students while allowing students the ability to learn and practice in a service line model. [ J Nurs Educ. 2017;56(12):745–747.]

Flint, Michigan switched to the Flint River as a temporary drinking water source without implementing corrosion control in April 2014. Ten months later, water samples collected from a Flint residence revealed progressively rising water lead levels (104, 397, and 707 μg/L) coinciding with increasing water discoloration. An intensive follow-up monitoring event at this home investigated patterns of lead release by flow rate-all water samples contained lead above 15 μg/L and several exceeded hazardous waste levels (5000 μg/L). Forensic evaluation of exhumed service line pipes compared to water contamination "fingerprint" analysis of trace elements, revealed that the immediate cause of the high water lead levels was the destabilization of lead-bearing corrosion rust layers that accumulated over decades on a galvanized iron pipe downstream of a lead pipe. After analysis of blood lead data revealed spiking lead in blood of Flint children in September 2015, a state of emergency was declared and public health interventions (distribution of filters and bottled water) likely averted an even worse exposure event due to rising water lead levels.

Lead service lines (LSLs)&mdash, lead pipes connecting the water main under the street to a building&rsquo, s plumbing&mdash, contribute an estimated 50% to 75% of lead in tap water when they are present. Although Congress banned lead in plumbing materials in 1986, over 6 million LSLs remain in homes across the United States today. This paper summarizes three different home buying or renting scenario-based experimental studies used to evaluate disclosure styles, to assess if these influenced respondents&rsquo, perceived risk of the LSL in a home, and their willingness to act. In renting scenarios, having landlords disclose the presence of an LSL, but also provide water test results showing lead levels below the EPA&rsquo, s lead action level resulted in lower levels of perceived risk, and of willingness to act. In seller-disclosure home buying scenarios, levels of perceived risk and willingness to act were consistently high, and three different disclosure styles did not differentially influence those outcomes. In home inspector-disclosure home buying scenarios, levels of perceived risk and willingness to act were high, but having explicit recommendations to replace LSLs and/or information about risk did not further influence those outcomes. In some cases, including the specific recommendations backfired. Implications for policy and regulation are discussed.

Recently, quality, financial, and regulatory demands have driven physicians to seek alignment opportunities with hospitals. The motivation for alignment on the part of physicians and hospitals is now accelerating because the new paradigm under healthcare reform requires an increased focus on improving quality, cost, and efficiency.We (1) identify the key drivers for physician-hospital alignment models; (2) summarize comanagement as a physician-hospital alignment model; and (3) explore a detailed case study of comanagement as an option to better align physicians with hospital goals on quality, safety, and outcomes.A Medline abstract review was performed that identified 45 references that discuss options for physician-hospital alignment. None of the articles identified provide a detailed example of successful alignment structures. A detailed case study of a successful comanagement alignment program is reviewed.The key drivers for alignment are inpatient growth rates, declining reimbursements, and the opportunity to improve quality, decrease costs, and increase efficiency. Two general strategies of alignment involve noneconomic and/or economic integration. In our example, comanagement with economic integration was chosen as the preferred structure for physician-hospital alignment.The choice of structure will vary depending on the existing relationships and governance of the hospital and the physicians in the targeted area of focus. The measure of success in building physician-hospital alignment is measured in improvements in care for the patient, reduced cost of care delivery, and improved relations between physicians and hospital leadership.

Dwellings with/without a lead service line [LSL] were sampled for lead in tap water in Montreal, during different seasons. Short-term simulations using these results and the batchrun mode of the Integrated Exposure Uptake Biokinetic (IEUBK) model showed that children's exposure to lead at the tap in the presence of an LSL varies seasonally, and according to the type of dwelling. From July to March, for single-family homes, the estimated geometric mean [GM] blood lead level [BLL] decreased from 2.3-3.6 μg/dL to 1.5-2.5 μg/dL, depending on the children's age. The wide seasonal variations in lead exposure result in a minimal fraction (0-6%) of children with a predicted BLL >5 μg/dL in winter, as opposed to a significant proportion (5-25%) in summer. These estimations are in close agreement with the BLLs measured in Montreal children in fall and winter, and simulations using summer water lead levels illustrate the importance of measuring BLLs during the summer. Finally, simulations for wartime residences with long LSLs confirm the need to prioritize the control of this lead exposure from tap water.

Release of lead from 80% partially replaced service lines was compared to full lead service lines using harvested-stabilized lead pipes and field brass connectors. After more than a year of stabilization, lead release was consistent with field samples. Over the relatively short duration partial replacement of lead pipe by copper pipe (3 months), generated high lead release, attributed to galvanic corrosion, resulting in a final outcome for lead release that was even worse than for a full lead pipe. Increased lead release was especially evident at higher flow rates. Orthophosphate reduced lead release from full lead pipes by 64%. For partially replaced samples with copper, lead concentrations were unchanged by phosphate dosing at moderate flow (103 ± 265 vs 169 ± 349 μg/L) and were increased to very high levels when sampled at high flow rates (1001 ± 1808 vs 257 ± 224 μg/L). The increase lead release was in the form of particulate lead (>90%). In comparison to the condition without treatment, increased sulfate treatment had little impact on lead release from 100%-Pb rigs but reduced lead release from partially replaced lead pipes with copper. Our results also raise questions concerning protocols based on short 30 min stagnation (as those used in Canada) due to their incapacity to consider particulate lead release generated mostly after longer stagnation.

Within the past 3 decades, a recent trend in the growth of musculoskeletal service lines has been seen nationally. Orthopedics offers an appealing concourse for implementation of service-line care. Within this review, the authors address the components involved in planning and building a musculoskeletal service line. The authors also address methods by which orthopedic surgeons can maintain the efficacy of their service lines by examining how orthopedic surgeons can navigate their service line through recent advents in health care reform. Finally, the authors review successful examples of musculoskeletal service lines currently in practice within the orthopedic community.

Purpose: Implementation of a co-management services agreement (Co-MSA) creates agreed-upon cancer care delivery quality metrics, a forum for discussion of service line oversight, and virtually integrated care without institutional employment of oncologists. The goal of this project was to demonstrate that a Co-MSA improved predefined quality metrics and provided enhanced communications between a health system’s oncology service line and a group of independent oncologists. Methods: Iterative planning discussions were scheduled biweekly over an 18-month period. Contractual, quality, and clinical data with benchmarking were considered in the creation of the Co-MSA. Review of the first year’s implementation occurred through examination of the metric achievements and qualitative themes that arose through committee meetings, clinical implementation processes, and cross-organizational discussions. Results: Metrics designed for the Co-MSA included improved adherence to the breast cancer, colon cancer, and non–small-cell lung cancer level I pathways; improvement of the medical oncology physician communication component of the hospital system’s Hospital Consumer Assessment of Healthcare Providers and Systems survey scores; and increased delivery of survivorship care plans to appropriate patients. Nonquantifiable themes from the first year of implementation included the need for technology to collect data, both organizations needing a wider understanding of quality improvement techniques, and a need for greater executive leadership involvement. Conclusion: In its first year, the Co-MSA resulted in improvement of the delivery of survivorship care plans and adherence to value pathways powered by the National Comprehensive Cancer Network. Improvement of Hospital Consumer Assessment of Healthcare Providers and Systems scores did not occur.

Purpose We tested the hypothesis that establishing a dedicated interventional oncology (IO) clinical service line would increase clinic visits and procedural volumes at a single quaternary care academic medical center. Methods Two time periods were defined: July 2012 to June 2013 (pre-IO clinic) and July 2013 to June 2014 (first year of dedicated IO service). Staff was recruited, and clinic space was provided in the institution's comprehensive cancer center. Clinic visits and procedure numbers were documented using the institution's electronic medical record and billing forms. IO procedures included were transarterial chemoembolization, Y-90 radioembolization, perfusion mapping for Y-90, portal vein embolization, and bland embolization. We compared changes in clinic visit and procedure numbers using paired t tests. Changes after IO initiation were compared to 1-year changes in the Medicare 5% Limited Data Set by cross-referencing Current Procedure Terminology and International Classification of Diseases codes in 2012 and 2013. Results Clinic visits increased from 9 to 204 ( P = .003, t = 8.89, df = 3). Procedures increased from 60 to 239 ( P = .018, t = 3.85, df = 4). Procedural volumes increased at least 150% for each subtype. The volumes in the 5% Limited Data Set did not change significantly over the 2-year period (443 to 385, P > .05). Conclusions The establishment of a dedicated IO service significantly increased clinic visits and procedural volumes. National trends were unchanged, suggesting that the impact of our program was not part of a sudden increase of IO procedures.

The thoughtful development and implementation of a comprehensive obstetric/gynecologic (OB/GYN) hospitalist program can result in a cost-effective practice model that provides increased value through a wide variety of services. The continuous on-site availability of an OB/GYN specialist affords many benefits to patients, hospitals, and practicing physicians. A well-implemented and effective OB/GYN hospitalist program will be associated with many different service line improvements for hospitals. Such programs increase patient safety, promote risk reduction, and improve clinical outcomes, while enriching the quality of life of obstetricians and gynecologists.

Building a radiology service line is a challenge. Beyond the science of imaging and pathophysiology of disease, there are a number of key elements and necessary actions--related to personnel, communication, and resources--that must be taken to make the service line successful and sustainable. Although there is no single best way to build an imaging-based service line, there are a number of essential components. The purpose of this article is to delineate these components and describe how ambitious radiologists may successfully build and sustain a radiology service line.

As health care delivery reform continues in the United States, the need for care integration is increasingly obvious. Long-term mitigation of cost trends will likely require care coordination of patients with multiple comorbidities, since about 5% of patients account for almost 50% of health care costs. Successful care coordination of this type of patient begins with accurate patient identification and then tracking of selected patients across the care continuum, both dependent on an all-inclusive health system electronic medical record. This month’s Practice Management article describes innovative work at Yale University School of Medicine and Yale New Haven Hospital. There, clinicians worked with experts in the hospital’s Cost and Value Department to identify all patients with liver disease and then track their clinical care and resource use over a 12-month period. These data then were used to categorize patients into medically logical subpopulations where targeted clinical interventions could be applied to affect patient and financial outcomes.

BackgroundRevision THA and TKA are growing and important clinical and economic challenges. Healthcare systems tend to combine revision joint replacement procedures into a single service line, and differences between revision THA and revision TKA remain incompletely characterized. These differences carry implications for guiding care and resource allocation. We therefore evaluated epidemiologic trends associated with revision THAs and TKAs.Questions/purposesWe sought to determine differences in (1) the number of patients undergoing revision TKA and THA and respective demographic trends; (2) differences in the indications for and types of revision TKA and THA; (3) differences in patient severity of illness scoring between THA and TKA; and (4) differences in resource utilization (including cost and length of stay [LOS]) between revision THA and TKA.MethodsThe Nationwide Inpatient Sample (NIS) was used to evaluate 235,857 revision THAs and 301,718 revision TKAs between October 1, 2005 and December 31, 2010. Patient characteristics, procedure information, and resource utilization were compared across revision THAs and TKAs. A revision burden (ratio of number of revisions to total number of revision and primary surgeries) was calculated for hip and knee procedures. Severity of illness scoring and cost calculations were derived from the NIS. As our study was principally descriptive, statistical analyses generally were not performed; however, owing to the large sample size available to us through this NIS analysis, even small observed differences presented are likely to be highly statistically significant.ResultsRevision TKAs increased by 39% (revision burden, 9.1%-9.6%) and THAs increased by 23% (revision burden, 15.4%-14.6%). Revision THAs were performed more often in older patients compared with revision TKAs. Periprosthetic joint infection (25%) and mechanical loosening (19%) were the most common reasons for revision TKA compared with dislocation (22%) and mechanical loosening (20%) for revision THA. Full (all-component) revision was more common in revision THAs (43%) than in TKAs (37%). Patients who underwent revision THA generally were sicker (>50% major severity of illness score) than patients who underwent revision TKA (65% moderate severity of illness score). Mean LOS was longer for revision THAs than for TKAs. Mean hospitalization costs were slightly higher for revision THA (USD 24,697+/-USD 40,489 [SD]) than revision TKA (USD 23,130+/-USD 36,643 [SD]). Periprosthetic joint infection and periprosthetic fracture were associated with the greatest LOS and costs for revision THAs and TKAs.ConclusionsThese data could prove important for healthcare systems to appropriately allocate resources to hip and knee procedures: the revision burden for THA is 52% greater than for TKA, but revision TKAs are increasing at a faster rate. Likewise, the treating clinician should understand that while both revision THAs and TKAs bear significant clinical and economic costs, patients undergoing revision THA tend to be older, sicker, and have greater costs of care.

Varicose vein management presents an exciting opportunity for the expansion of the interventional components of many practices. Although vein practice development has been addressed by other specialists, concerns unique to radiologists have only lately become important. Radiology groups are well suited to support the addition of this service line, and it may serve as a showcase for further clinical growth. Success depends on appropriate business planning, clinical and administrative infrastructure, and intelligent marketing. This article describes requisites for the successful development of a phlebology practice by a radiology group.

Health care reform has posed special challenges for departments of psychiatry in academic medical centers. This report describes one department's strategic responses to a marketplace with high penetration by managed care and provides examples of the kinds of faculty concerns that can arise when major departmental reorganizations are attempted. The department's successful adaptation to a radically altered professional environment is attributed to the following five initiatives: vertical integration and diversification of clinical programs, service line management, outcomes measurement, regional network development, and institutional managed care partnerships Although the authors did not design their adaptive efforts as a research study, they offer objective data to support their conclusion that the viability of their overall clinical enterprise has been sustained despite an external environment inhospitable to academic psychiatry.

BACKGROUND Hospital-physician vertical integration involving employment of physicians has increased considerably over the last decade. Cardiologists are one group of specialists being increasingly employed by hospitals. Although hospital-physician integration has the potential to produce economic and societal benefits, there is concern that this consolidation may reduce competition and concentrate bargaining power among providers. In addition, hospitals may be motivated to offer cardiologists higher compensation and reduced workloads as an incentive to integrate. PURPOSE The aim of the study was to determine if there are differences in compensation and clinical productivity, measured by work relative value units (RVUs), for cardiologists as they transition from being independent practitioners to being employed by hospitals. METHODOLOGY/APPROACH This study was a quantitative, retrospective, longitudinal analysis, comparing the compensation and work RVUs of integrated cardiologists to their compensation and work RVUs as independent cardiologists. Data from the MedAxiom Annual Survey from 2010 to 2014 were used. Participants included 4,830 unique cardiologists that provided 13,642 pooled physician-year observations, with ownership status, compensation, work (RVUs), and other characteristics as variables for analysis. RESULTS Results from the multivariate regressions indicate that average compensation for cardiologists increases by $129,263.1 (p < .001) when they move from independent to integrated practice. At the same time, physician work RVUs decline by 398.04 (p = .01). CONCLUSION Our findings support the conjecture that hospitals may be offering higher pay and lower workloads to incentivize cardiologists to integrate. PRACTICE IMPLICATIONS Although hospitals may have goals of quality improvement and lower costs, such goals may presently be secondary to service line growth and increased market power. There is reason to be cautious about some of the implications of hospital integration of cardiologists.

Background:Cities across the U.S. and internationally are adopting Bus Rapid Transit to improve transit services for residents. Features of Bus Rapid Transit include fewer stops, dedicated bus lanes, and expedited systems for boarding busses, compared with regular bus service. This study examines whether Bus Rapid Transit (BRT) ridership is associated with increased rates of walking, because of the greater distance between BRT stops compared with regular bus service.Methods:Surveys were conducted with riders of local and BRT buses for New York City’s M15 Select Bus Service line. Surveys examined bus ridership, health status and physical activity, walking rates, and demographic information.Results:BRT riders reported walking approximately half a block more than did local bus riders. The average number of blocks walked decreased for BRT riders who previously used the subway before the implementation of the BRT.Conclusions:BRT may be a useful tool to support walking for some groups. Depending on where it is implemented, BRT may also be associated with reduced walking among users who switch to BRT from other active transportation modes. Future research should examine associations between walking and BRT ridership with a larger sample and more sites.

The idea that detailed knowledge of molecular oncogenesis will drive diagnostic, prognostic, and therapeutic clinical decision making in an increasingly multidisciplinary practice of oncologic care has been anticipated for many years. With the recent rapid advancement in our understanding of the molecular underpinnings of genitourinary malignancies, this concept is now starting to take shape in the fields of prostate, kidney, bladder, testicular, and penile cancer. Such breakthroughs necessitate the development of robust clinical-grade assays that can be quickly made available for patients to facilitate diagnosis in challenging cases, risk-stratify patients for subsequent clinical management, select the appropriate targeted therapy from among increasingly diverse and numerous options, and enroll patients in advanced clinical trials. This rapid translation of basic and clinical cancer research requires a streamlined, multidisciplinary approach to clinical assay development, termed here the molecular diagnostics service line laboratory. In this review, we summarize the current state and explore the future of molecular diagnostics in genitourinary oncology to conceptualize a genitourinary service line laboratory at a tertiary clinical institution.

The traditionally organized, functionally structured nature of hospitals is no longer affordable in today's economic environment. Managed care, the outcomes movement, and changed stakeholders have challenged hospitals to become more patient centered with seamless, streamlined operations. A service line approach focusing on patient populations across a broad continuum of care offers a system that maximizes results. Strong leadership that emphasizes a clear vision of the future, a process-oriented organizational structure, multidisciplinary clinical practice, performance-based management, and broadened roles that emphasize lifelong learning have contributed to the success of the cardiac service at Virginia Heart Center. Nurse managers have taken the lead at this center in achieving superior performance.