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Biofilm detachment contributes to water quality deterioration. However, the contributions of biofilm detachment from different pipes have not been quantified or compared. Following the introduction of partial reverse osmosis (RO) in drinking water production, this study analyzed particles at customers’ ends and tracked their origins to water distribution mains and service lines. For doing so, filter bags were installed in front of water meters to capture upstream detached particles, while biofilm from water main and service line were sampled by cutting pipe specimens. The results showed that elemental concentrations of the biofilm in mains were higher than those of service lines (54.3–268.5 vs. 27.1–44.4 μg/cm2), both dominated by Ca. Differently, filter bags were dominated by Fe/Mn (77.5–98.1%). After introducing RO, Ca significantly decreased in biofilms of mains but not service lines, but the released Fe/Mn rather than Ca arrived at customers’ ends. The ATP concentrations of service lines were higher than mains, which decreased on mains but increased in service lines after introducing RO. For the core ASVs, 13/24 were shared by service lines (17), mains (21), and filter bags (17), which were assigned mainly to Nitrospira spp., Methylomagnum spp., Methylocytis spp., and IheB2–23 spp. According to source tracking results, service lines contributed more than mains to the particulate material collected by filter bags (57.6 ± 13.2% vs. 13.0 ± 11.6%). To the best of our knowledge, the present study provides the first evidence of service lines’ direct and quantitative contributions to potential water quality deterioration at customers’ ends. This highlights the need for the appropriate management of long-neglected service line pipes, e.g., regarding material selection, length optimization, and proper regulation.

In this paper, we examine whether the format of service lines affects customers’ satisfaction with their queuing experience. Using a goal-theoretic approach, and data from a series of experimental studies, we show that the duration of the wait moderates the psychological tradeoff between the initial queue length and its rate of movement, such that customers prefer a single line format for shorter waits but a multiple line format for longer waits. We also show that satisfaction declines with an increase in the number of stages in service lines. This adverse effect of multi-staging can be mitigated by using information devices as well as orienting customers away from local, stage-specific, sub-goals towards the overall goal of receiving service and exiting the system. We synthesize these findings about the psychophysics of queuing to generalize a model of satisfaction with waiting that accounts for the effect of service line formats and can represent customers’ utility functions in models of queuing systems.

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.

In April 2014, Flint, MI switched its drinking water source from water treated in Detroit to Flint River water without applying corrosion control. This caused lead and other metals to leach into drinking water. To mitigate lead exposure, Flint began to replace lead service lines and galvanized iron service lines in March 2016. In this study, the short- and long-term impact of service line replacement on Flint drinking water quality was investigated. In particular, lead and other metal concentrations, chlorine residual, and levels of select microbial populations were examined before and two and five weeks after SL replacement in water collected from 17 Flint homes. Overall, lead levels in premise plumbing water did not change significantly within five weeks of replacement, however, significant reductions were observed two weeks after service line replacement in flushed samples representative of distribution system water (pre-replacement median = 0.98 μg L−1; two-week post-replacement median = 0.11 μg L−1). Multiple sequential samplings from one Flint residence before and 11 months after service line replacement revealed large reductions in lead levels in all samples, indicating long-term benefits of service line replacement. Cadmium was also detected at levels at or above the federal maximum contaminant level. Microbial analyses established that 100%, 21%, and 52% of samples had quantifiable concentrations of total bacteria, Legionella spp., and Mycobacterium spp. as measured by quantitative PCR, while Legionella pneumophila was not detected in any samples. Our results provide evidence that both lead service line and galvanized service line replacement benefit consumers in the long term by reducing drinking water lead concentrations, while short-term advantages of service line replacement in sites with prior lead seeding of in-home plumbing are less apparent.

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.

The population of older adults in the United States is expanding rapidly. With this expansion, the healthcare system, and emergency departments (EDs) in particular, should provide geriatric‐focused care tailored to the needs of this population. To this end, the American College of Emergency Physicians (ACEP) released a geriatric emergency department accreditation (GEDA) to certify EDs that have the staffing, training, and resources to provide high‐quality, geriatric‐focused, emergent care. Our healthcare system set out to achieve the GEDA at all system hospitals using a service‐line approach and standardized policies. The implementation and application process was completed through strong partnerships between the Emergency Medicine Service Line and the Division of Geriatrics and Palliative Medicine. Further partnerships with ACEP were vital to completing the application process and using a standardized application. Through these partnerships, all 17 of our system hospitals achieved tier 3 accreditation. Through this process, we were able to identify opportunities to improve the care provided to older adults in the ED, particularly via staff education. We also gathered lessons learned for system‐level accreditation, including fostering close partnerships, meeting the unique needs of each ED, and strategically planning when and where to increase tier levels. This practice of large‐scale, system‐wide standardization, rather than individual site implementation, is an effective measure to provide geriatric‐focused care to the large and growing population of older adults.

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.

The article defines the relevance of delivery on the principle of «just-in-time» for the river transport and presents a developed algorithm for the transition to ensuring delivery on time on individual river shipping lines. An approbation of the proposed scientific and methodological approach to ensuring delivery on time was carried out using the example of the existing river service line, within which measures were developed to stabilize the delivery operations according to the current destabilizing factors and their effectiveness was evaluated. The article presents methodology for estimating delivery options on the terms of on time delivery from the point of view of the cargo owner. The possibility and expediency of organizing delivery on time on individual river shipping lines has been proved, both from the point of view of cargo owners and from the point of view of shipping companies, taking into account the provision of counteraction to destabilizing factors.

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.

Car body fatigue reliability is a key technology for the development of railway heavy axle load freight cars. Therefore, a comprehensive test rig capable for carrying out car body fatigue test and complete car vibration test was designed and built in CRRC Qiqihar Rolling Stock Co., Ltd. (QRRS). This test rig was used to validate fatigue life of car body in accelerated fatigue test by simulating car body movement in service with input data derived from measurements in service lines. The success of such test depends on some key technologies such as collection of response signals in service line test, process of data collection, compilation of drive file for test rig, determination of test methods and evaluation of test results. A C70E-loaded general service gondola car was tested on test rig to evaluate its fatigue life with accumulated equivalent total mileage of 3.125 million kilometers. The test results indicate that this car body can survive for 25 years and meet designed life requirement. Comparison between response signals from test rig and target signals demonstrates that acceleration RMS error is less than 6%, and stress RMS error is less than 18% and fatigue accumulated damage error is less than 6%. It means that simulation accuracy of test rig has achieved the requirement. Such results demonstrate that related key technologies are applicable and suitable.

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.

Background Length of stay (LOS) can be used to measure cost savings when expressed in terms of opportunity days. Using simple tools to assess the percent of contribution for opportunity days by facility and service line, along with a financial target and standard proxy cost per day, LOS goals can be established for the number of opportunity days to save for each facility and service line within a healthcare system. Objectives Utilize percent of opportunity day contributions to set acute care facility and service line targets based upon a financial goal for a healthcare system. Methods Targets for LOS opportunity days to save are determined based upon the proportion of the financial goal each facility is expected to contribute to the overall cost savings. An opportunity day is defined as the difference between the number of days a patient stays in the hospital versus the number of days they were expected to stay, determined by Care Science risk adjustment (figure 1). Opportunity days to be saved were translated into an Observed/Expected (O/E) Ratio target for each facility (figure 2). Results LOS reduction efforts resulted in days saved in non-COVID patients, but the negative savings from COVID patients resulted in a net loss of opportunity days when all patients were bundled together (figure 3). Calculations for opportunity days saved were modified to account for the decrease of inpatient volumes and subsequent analysis of the data included stratification for the COVID vs. non-COVID population. Conclusions The model described for combining a financial goal by facility with opportunity days enables the setting of LOS targets for healthcare systems. Further, the model supports tracking progress to targets, including the ability to compare specific patient types, e.g., COVID-19 Positive vs. COVID-19 Negative (figure 4).

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.