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OBJECTIVES For hospitalized children and their families, laboratory study collection at night and in the early morning interrupts sleep and increases the stress of a hospitalization. To change this practice, our quality improvement (QI) study developed a rounding checklist aimed at increasing the percentage of routine laboratory studies ordered for and collected after 7 am. METHODS Our QI study was conducted on the pediatric hospital medicine service at a single-site urban children’s hospital over 28 months. Medical records from 420 randomly selected pediatric inpatients were abstracted, and 5 plan-do-study-act cycles were implemented during the intervention. Outcome measures included the percentage of routine laboratory studies ordered for and collected after 7 am. The process measure was use of the rounding checklist. Run charts were used for analysis. RESULTS The percentage of laboratory studies ordered for after 7 am increased from a baseline median of 25.8% to a postintervention median of 75.0%, exceeding our goal of 50% and revealing special cause variation. In addition, the percentage of laboratory studies collected after 7 am increased from a baseline median of 37.1% to 76.4% post intervention, with special cause variation observed. CONCLUSIONS By implementing a rounding checklist, our QI study successfully increased the percentage of laboratory studies ordered for and collected after 7 am and could serve as a model for other health care systems to impact provider ordering practices and behavior. In future initiatives, investigators should evaluate the effects of similar interventions on caregiver and provider perceptions of patient- and family-centeredness, satisfaction, and the quality of patient care.

The purpose of this policy statement is to update the 2004 American Academy of Pediatrics clinical report and provide enhanced guidance for institutions, administrators, and providers in the development and operation of a pediatric intermediate care unit (IMCU). Since 2004, there have been significant advances in pediatric medical, surgical, and critical care that have resulted in an evolution in the acuity and complexity of children potentially requiring IMCU admission. A group of 9 clinical experts in pediatric critical care, hospital medicine, intermediate care, and surgery developed a consensus on priority topics requiring updates, reviewed the relevant evidence, and, through a series of virtual meetings, developed the document. The intended audience of this policy statement is broad and includes pediatric critical care professionals, pediatric hospitalists, pediatric surgeons, other pediatric medical and surgical subspecialists, general pediatricians, nurses, social workers, care coordinators, hospital administrators, health care funders, and policymakers, primarily in resource-rich settings. Key priority topics were delineation of core principles for an IMCU, clarification of target populations, staffing recommendations, and payment.

A bridge course intended to ease the transition from Organic Chemistry I to II was designed for a January term that spans 2 weeks and features sharply focused topics courses. In the first week, key...

Creatine dilution (D 3-cr) is a technique for estimating total skeletal muscle mass (SMM) with practical utility, but has not been applied in athletic populations where body composition may differ to that in the normal population. This study aimed to assess the agreement between SMM derived from both D 3-cr and that obtained from whole-body magnetic resonance imaging (MRI) in 15 male and 5 female national level kayakers (stature: 182.0 ± 13.1 and 170.0 ± 9.0 cm; body mass: 80.6 ± 9.9 and 66.4 ± 6.0 kg; V̇O 2peak: 56.5 ± 7.0 and 49.6 ± 4.4 mL kg −1 min −1, mean ± SD). SMM was determined following 60 mg of dosed D 3-cr and analysis of expelled urine collected on four subsequent days for creatine, creatinine, D 3-cr, and D 3-creatinine using liquid chromatography/mass spectroscopy. SMM was then estimated by assuming a creatine pool size of 4.3 g/kg. During the same time period, a whole-body MRI was undertaken to derive SMM from the analysis of multiple slices taken across the body. A strong positive correlation (F = 74.32; R = 0.90; P 3-cr SMM was found to be significantly higher (43.3 ± 6.8 kg) when compared with MRI (36.3 ± 5.8 kg, P 3-cr has potential utility in athletes, as referenced against MRI, but show that assumptions regarding creatine pool size need to be carefully considered.

BACKGROUND The Centers for Medicare and Medicaid Services has emphasized patient satisfaction as a means by which hospitals should be compared and as a component of financial reimbursement. We sought to identify whether resource utilization is associated with patient satisfaction ratings. DESIGN This was a retrospective, cohort study over a 27-month period from January 2012 to April 2014 of adult respondents (n = 10,007) to the Hospital Consumer Assessment of Healthcare Providers and Systems survey at a tertiary care medical center. For each returned survey, we developed a resource intensity score related to the corresponding hospitalization. We calculated a raw satisfaction rating (RSR) for each returned survey. Multivariable logistic regression was used to determine the association between resource intensity and top decile RSRs, using those with the lowest resource intensity as the reference group. RESULTS Adjusting for age, gender, insurance payer, severity of illness, and clinical service, patients in higher resource intensity groups were more likely to assign top decile RSRs than the lowest resource intensity group (“moderate” [adjusted odds ratio {aOR}: 1.42, 95% confidence interval {CI}: 1.11-1.83], “major” [aOR: 1.56, 95% CI: 1.22-2.01], and “extreme” [aOR: 2.29, 95% CI: 1.8-2.92]). CONCLUSIONS Resource utilization may be positively associated with patient satisfaction. These data suggest that hospitals with higher per-patient expenditures may receive higher ratings, which could result in hospitals with higher per-patient resource utilization appearing more attractive to healthcare consumers. Journal of Hospital Medicine 2016. © 2016 Society of Hospital Medicine

The Proportional Responsibility for Integrated Metrics by Encounter (PRIME) model is a novel means of allocating patient experience scores based on the proportion of each physician's involvement in care. Secondary analysis was performed on Hospital Consumer Assessment of Healthcare Providers and Systems surveys from a tertiary care academic institution. The PRIME model was used to calculate specialty-level scores based on encounters during a hospitalization. Standard and PRIME scores for services with the most inpatient encounters were calculated. Hospital medicine had the most discharges and encounters. The standard model generated a score of 74.6, while the PRIME model yielded a score of 74.9. The standard model could not generate a score for anesthesiology due to the lack of returned surveys, but the PRIME model yielded a score of 84.2. The PRIME model provides a more equitable method for distributing satisfaction scores and can generate scores for specialties that the standard model cannot.

Aims and objectives This study aimed to determine the interobserver reliability between bedside nurses and attending physicians for a paediatric respiratory score as part of an asthma Integrated Care Pathway implementation. Background An Integrated Care Pathway is one approach to improving quality of care for children hospitalised with asthma. Prior to implementation of the integrated care pathway, it was necessary to train nursing staff on the use of a respiratory assessment tool and to evaluate the interobserver reliability use of this tool. Design Prospective study using a convenience sample of children hospitalised for a respiratory illness in an academic medical centre. Methods The respiratory assessment used was the Paediatric Asthma Score. Bedside nurse-attending physician (27 different RNs and three attending paediatric hospitalists) pairs performed 71 simultaneous patient assessments on 20 patients. Intraclass correlation coefficient and kappa statistics were used to assess interobserver reliability. Results The overall intraclass correlation coefficient was nearly perfect where κ = 0·95, 95% CI (0·92, 0·97) and overall kappa for reliability based on clinically relevant score breakpoints was also high with κ = 0·82, 95% CI (0·75, 0·90). The majority of subgroup analyses revealed substantial to almost perfect agreement across a variety of diagnoses, age ranges, and individual score components. Conclusions Bedside nurses, with support and training from attending physicians, can perform respiratory assessments that agree almost perfectly with those of attending physicians. Relevance to clinical practice The use of an Integrated Care Pathway allows for optimal interprofessional collaboration between bedside nurses and attending physicians.

Current methods for clinical estimation of total body skeletal muscle mass have significant limitations. We tested the hypothesis that creatine ( methyl-d3) dilution (D3-creatine) measured by enrichment of urine D3-creatinine reveals total body creatine pool size, providing an accurate estimate of total body skeletal muscle mass. Healthy subjects with different muscle masses [ n = 35: 20 men (19–30 yr, 70–84 yr), 15 postmenopausal women (51–62 yr, 70–84 yr)] were housed for 5 days. Optimal tracer dose was explored with single oral doses of 30, 60, or 100 mg D3-creatine given on day 1. Serial plasma samples were collected for D3-creatine pharmacokinetics. All urine was collected through day 5. Creatine and creatinine (deuterated and unlabeled) were measured by liquid chromatography mass spectrometry. Total body creatine pool size and muscle mass were calculated from D3-creatinine enrichment in urine. Muscle mass was also measured by magnetic resonance imaging (MRI), dual-energy x-ray absorptiometry (DXA), and traditional 24-h urine creatinine. D3-creatine was rapidly absorbed and cleared with variable urinary excretion. Isotopic steady-state of D3-creatinine enrichment in the urine was achieved by 30.7 ± 11.2 h. Mean steady-state enrichment in urine provided muscle mass estimates that correlated well with MRI estimates for all subjects ( r = 0.868, P < 0.0001), with less bias compared with lean body mass assessment by DXA, which overestimated muscle mass compared with MRI. The dilution of an oral D3-creatine dose determined by urine D3-creatinine enrichment provides an estimate of total body muscle mass strongly correlated with estimates from serial MRI with less bias than total lean body mass assessment by DXA.

The chemistry department at Washington & Jefferson College implemented an “organic first” curriculum in the fall semester of 2005. Assessment data suggest that the net impact of this change for the department and associated constituencies has been positive: (i) Student outcomes have generally not been impacted by the curricular change, though a significant improvement in student performance on a standardized analytical exam has been observed. (ii) The department has attracted more majors, and can use faculty resources differently as a two-semester general chemistry sequence is no longer offered. (iii) The biology program reports greater student success in introductory biology, in part because of the organic chemistry background students now acquire earlier.

Background: Current methods to measure skeletal muscle mass are not practical in a clinical setting. Liquid chromatography–tandem mass spectrometry (LC–MS/MS) methods that measure the amount of urinary d3-creatinine enrichment after a single tracer dose of d3-creatine was developed. Results: The biomarkers d3-creatinine and creatinine were detected in human urine using LC–MS/MS. In this assay a surrogate analyte, d3-creatinine, was used to quantify endogenous creatinine. However, since endogenous concentrations of creatinine were orders of magnitude higher than d3-creatinine, the peak area of a less intense isotope of creatinine was acquired. A response factor is used to correct for using a less intense isotope multiple reaction monitoring transition. Conclusion: Novel LC–MS/MS assays were developed that quantify the biomarkers d3-creatinine, creatinine and d3-creatine in urine. This method allows the estimation of total body creatine pool size and subsequent calculation of muscle mass. This assay was originally validated as fit-for-purpose and was followed by full validation.

BACKGROUND Many academic pediatric hospital medicine (PHM) divisions have recently increased in-house supervision of residents, often providing 24/7 in-house attending coverage. Contrary to this trend, we removed mandated PHM attending input during the admission process. We present an evaluation of this process change. METHODS This cohort study compared outcomes between patients admitted to the PHM service before (July 1, 2011–September 30, 2011) and after (July 1, 2012–September 30, 2012) the process change. We evaluated time from admission request to inpatient orders, length of stay (LOS), frequency of change in antibiotic choice, and rapid response team (RRT) calls within 24 hours of admission. Data were obtained via chart abstraction and from administrative databases. Wilcoxon rank sum and Fisher exact tests were used for analysis. RESULTS We identified 182 and 210 admissions in the before and after cohorts, respectively. Median time between emergency department admission request and inpatient orders was significantly shorter after the change (123 vs 62 minutes, P

Background We recently validated in cross-sectional studies a new method to determine total body creatine pool size and skeletal muscle mass based on D3-creatine dilution from an oral dose and detection of urinary creatinine enrichment by isotope ratio mass spectrometry (IRMS). Routine clinical use of the method in aging and disease will require repeated application of the method, with a more widely available technology than IRMS, to enable determination of change in skeletal muscle mass in longitudinal studies. We therefore adapted the method to liquid chromatography-tandem mass spectrometry (LC-MS/MS) technology, and sought to establish proof of concept for the repeated application of the method in a longitudinal study. Because the turnover of creatine is slow, it was also critical to determine the impact of background enrichment from an initial dose of oral D3-creatine on subsequent, longitudinal measurements of change in muscle mass. Methods Rats were given an oral tracer dose of D3-creatine (1.0 mg/kg body weight) at 10 and 17 weeks of age. LC-MS/MS was used to determine urinary D3-creatine, and urinary D3-creatinine enrichment, at time intervals after D3-creatine administration. Total body creatine pool size was calculated from urinary D3-creatinine enrichment at isotopic steady state 72 h after administration of D3-creatine tracer. Results At 10 weeks of age, rat lean body mass (LBM) measured by quantitative magnetic resonance correlated with creatine pool size (r = 0.92, P = 0.0002). Over the next 7 weeks, the decline in urinary D3-creatinine enrichment was slow and linear, with a rate constant of 2.73 ± 0.06 %/day. Subtracting background urinary D3-creatinine enrichment from the elevated enrichment following a second dose of D3-creatine at 17 weeks permitted repeat calculations of creatine pool size. As at 10 weeks, 17-week LBM correlated with creatine pool size (r = 0.98, P

It is important for pediatric providers to be involved in quality improvement (QI) activities to improve children’s health outcomes.• The Model for Improvement asks several key questions related to a process, then uses Plan-Do-Study-Act(PDSA) cycles to implement, test, and spread changes.• Lean and Six Sigma methodologies can improve quality by increasing workflow efficiency and decreasing variation.• Root cause analysis (RCA) is a retrospective quality tool that helps determine factors contributing to errors and adverse events, so that improvements can be implemented.• Failure modes and effects analysis (FMEA) isa prospective quality tool that anticipates system vulnerabilities and helps develop risk reduction strategies.• Evidence-based interventions, such as best-practice guidelines, promote standardization and reduce errors and adverse events, especially in high-risk health-care settings.• Team training can improve communication and situational awareness to create a safer health-care environment.

1. Michael S. Leonard, MD, MS* 1. *Chief Quality & Safety Officer for Children's Services, Associate Professor of Pediatrics, University of Rochester Medical Center, Rochester, NY. After completing this article, readers should be able to: 1. Define terms commonly used in patient safety discourse. 2. Describe the scope of medical errors and adverse events, focusing on medication-related issues. 3. Identify barriers to improving patient safety. 4. Address disclosure of medical errors and adverse events. 5. Review principles and practices that can reduce the risk of harm to patients. This is the first in a series of articles to review the topics of patient safety and quality improvement in pediatrics. Patient safety is a subject that traverses all medical specialties and affects every health-care professional. The attention to medical errors and adverse events as well as the resultant literature has grown exponentially over the past decade. A number of practicing physicians, however, remain unaware of the extent of the problem, the impact on patients, and the burden on the health-care system. Many also are unfamiliar with strategies to reduce the risk of harm. It is important to note that definitions used in patient safety can vary across studies, between organizations, and over time. A medical error, as defined by the Institute of Medicine (IOM), is “the failure to complete a planned action as intended or the use of a wrong plan to achieve an aim.” (1)(2) It is a mistake in action or judgment. A medical error must be distinguished from an adverse event, which is “an injury caused by medical management rather than by the underlying disease or condition of the patient.” An adverse event results in harm to the patient. Not all medical errors lead to adverse events. In fact, most do not. A medication error is the most common …

Evidence- based practice (EBP) is an effective way for nurses to improve patient outcomes. Although EBP has gained popularity, barriers to implementation exist. This study explored whether mentoring neonatal intensive care unit (NICU) nurses in EBP would increase their participation in EBP. A sample of 20 nurses were mentored in an EBP project. The EBP Beliefs Scale and EBP Implementation Scale measured scores upon initiation and completion of the project. Statistical analysis showed no significant changes in nurses' beliefs in EBP or implementation of EBP following mentoring. However, a moderate degree of correlation between changes in beliefs scores and implementation scores was seen with a borderline significance. Age and years of experience did significantly influence changes in EBP beliefs scores. Although the study results did not support that mentoring changed attitudes or utilization of EBP, changes in NICU were implemented as a result of the project activities.

Cycloaromatization, via tandem cycloaddition – extrusion of carbon dioxide, between methyl isodehydroacetate or methyl coumalate and a variety of alkyne dienophiles has been investigated. This method provides an efficient synthesis of methyl 4-hydroxymethyl-2,6dimethylbenzoate (1), a key intermediate in the preparation of retinal-based molecular probes.

Condensation of ninhydrin with tryptamide or tryptamine followed by Lewis acid-induced rearrangement provided yohimbanones that were readily converted to β-carbolines via oxidative ring cleavage. The analogous condensation-rearrangement with 3,4-dimethoxyphenethylamine and ninhydrin afforded an oxyprotoberberine, which was further oxygenated at the 13a position.

The Proportional Responsibility for Integrated Metrics by Encounter (PRIME) model is a novel means of allocating patient experience scores based on the proportion of each physician's involvement in care. Secondary analysis was performed on Hospital Consumer Assessment of Healthcare Providers and Systems surveys from a tertiary care academic institution. The PRIME model was used to calculate specialty-level scores based on encounters during a hospitalization. Standard and PRIME scores for services with the most inpatient encounters were calculated. Hospital medicine had the most discharges and encounters. The standard model generated a score of 74.6, while the PRIME model yielded a score of 74.9. The standard model could not generate a score for anesthesiology due to the lack of returned surveys, but the PRIME model yielded a score of 84.2. The PRIME model provides a more equitable method for distributing satisfaction scores and can generate scores for specialties that the standard model cannot.

Most medical errors and preventable adverse events represent failures of complex systems. Pediatric clinicians must ensure a safe environment for health-care delivery to children. To do so, they must recognize risk factors for errors and adverse events; ensure effective communication with patients, parents, and colleagues; heighten situation awareness; develop high-functioning, high-reliability teams; implement and employ technology carefully; and provide integrated, ongoing education to trainees.

Transforming an organizational culture is a worthy and achievable endeavor, even when faced with limitations in funding and technology that appear as insurmountable obstacles. Equally ominous but necessary is the need to conquer commonplace problems such as medication errors. This paper will detail the means used at one hospital facility to make medication errors and their reduction a primary staff focus, and how a highly generalizable, low-tech and cost-conscious error-reduction methodology spurred a successful shift toward an organization-wide culture of patient safety.

The current Industrial Engineering curriculum implemented at most educational institutions in the United States is driven by curriculum reform included in the Roy Report which took place almost 40 years ago. It is clear that if Industrial Engineers are to keep pace with the changing environment we need to address the future of Industrial Engineering curriculum. In response, this paper outlines the development of a new scalable and deployable Industrial Engineering baccalaureate-degree curriculum renewal process. This model will be designed to permit scaling up from an information technology course kernel to a fully integrated Industrial Engineering undergraduate curriculum.

A mixture of a tri-block copolymer, poly(methyl methacrylate-ethyl acrylate-methacrylic acid), commercially known as Elvacite 2669, and sodium dodecyl sulfate (SDS) micelle was investigated as pseudo-stationary phase in Micellar Electrokinetic Chromatography (MEKC). The properties of the mixed system were characterized using surface tension and conductance experiments, as well as absorbance and fluorescence solvatochromic studies using ET(30) and pyrene as the probes. In this mixed system the SDS has a critical micelle concentration of 2 mM and the fluorescence data indicates that it has a microenvironment similar to SDS alone. Additionally, the solvation properties of the individual and the mixed systems were compared using linear solvation energy relationships (LSER). As compared to the SDS micelles, the mixed pseudo-phase is a weaker hydrogen bond donor and has stronger polarizability properties. The functional group selectivities in the mixed pseudo phase are different from that in the SDS micelle. The functional group selectivities of non-hydrogen bonding and hydrogen bonding solutes provide further support for the LSER findings.

When designing a product or process, a design engineer is often faced with a number of quality attributes and hence prioritizing the quality attributes is an inevitable task. Development of an adequate weight assessment system for multiple attributes in the early stage of design is crucial, since the choice of paths to quality enhancement depends heavily upon the type of weight assessment system used. Although several weight assessment methods are available in the literature, there is room for improvement. Most weight assessment methods reported in the research community have been developed from the perspective of either customers or a design engineer. This article proposes a hybrid weight assessment system by combining the perspectives of both parties, the customer and a design engineer, in such a way that uncertainty of human perceptions can be modeled using the concepts of fuzzy sets and Monte Carlo simulation. A model is presented and a numerical example is discussed.

Identifying the most influential scaling factor is critical in the early stage of product-family-based product design, but the issue has been inadequately address by researchers and not properly applied to real-world manufacturing problems. A scaling fa..

The synthesis and antitumor activity of a novel didemnin B analogue containing a Ψ[CH2NH] amide bond surrogate between N-Me- d -Leu7 and Pro8 are reported. The analogue shows activity (GI50=4 nM) comparable to that of didemnin B (GI50=13 nM) in the NCI-60 tumor cell screen. This result, along with new data from previously reported synthetic didemnin analogues, is discussed within the context of the side-chain SAR for didemnins.

A three-step synthesis was used to prepare several symmetrically substituted 1,4-bis [(aminoalkyl) amino]-5,8-dimethylanthracene-9, 10-diones commencing from 3,6-difluorophthalic anhydride.

A dimethylaminocoumarin fluorophore was linked to didemnin A through a glycine tether. The resultant fluorescent didemnin will be used to study cellular localization as detected by fluorescence microscopy.

Linear Solvation Energy Relationships (LSERs) are used to explain the congeneric behavior observed when using Micellar Electrokinetic Chromatography (MEKC) to estimate the octanol-water partition coefficient scale of solute hydrophobicity. Such studies provide useful insights about the nature of solute interactions that are responsible for the sources of congeneric relationships between MEKC retention and log Po/w. It was determined that solute dipolarity/polarizability and hydrogen-bonding character play the most important roles in the congeneric behavior observed for many surfactant systems. The individual dipolarity/polarizability and hydrogen-bonding contributions to the free energy of transfer were also investigated.

ABET Engineering Criteria 2000 require a selection of outcomes and outcome indicators for each educational objective adopted by an engineering program. This paper describes a database created using Microsoft Access 97 © linking choices of program outcomes and choices of program outcome indicators for all of the accredited engineering programs in an academic institution. With this database, benchmarking searches can be conducted by type of engineering program, by choice of outcome, or by choice of outcome indicator. Several example searches are presented using data describing the engineering programs at Clemson University. A web-site address is given where copies of the Clemson database can be downloaded.

This paper presents a set of related quasiconvex quality loss functions. Characteristics of quasiconvex functions that are desirable for modeling quality loss are noted. Three frequently used univariate quasiconvex quality loss functions are discussed. Bivariate and multivariate quasiconvex quality loss functions are developed. A set of necessary and sufficient conditions is established for the quasiconvexity of multivariate quality loss functions. An industrial product example is used to illustrate the development of a bivariate quadratic quality loss function.

We recently described a new method to determine total body creatine pool size and skeletal muscle mass based on dilution of an oral dose of D3-creatine in urinary creatinine. Enrichment of D3- crea...

The aporhoeadane alkaloids, exemplified by the natural products chilenine and lennoxamine, have received significant attention from the synthetic community over the course of nearly 50 years. This review details the approaches to these heterocycles, as well as their major reactions.