Service Line Research Articles

Assessment of an inpatient dermatology service line in the rural United States.

Assessment of an inpatient dermatology service line in the rural United States.

Hospital Network Centralization of Primary Total Joint Arthroplasty Is Associated With Reduced Early Complication Rates But Not Reduced Readmission or Reoperation Rates: A Retrospective Database Study

Background: Hospital networks centralize primary total joint arthroplasty (TJA) within their existing systems to develop specialized service lines with higher surgical volumes to reduce adverse events. It is not known what role hospital network centralization has had on primary TJA outcomes. Purpose: We sought to determine whether the degree of hospital network centralization for primary TJA is associated with (1) 90-day postoperative complication rates, (2) 90-day hospital readmission rates, or (3) 1-year revision rates. Methods: We conducted a retrospective database study of Medicare Part A beneficiaries who underwent inpatient primary TJA for osteoarthritis in 2016 and 2017 ( n = 523,142 patients); individual hospital-level characteristics and hospital networks were also identified ( n = 360 unique networks, n = 3339 hospitals). Patients having surgery at a hospital that was not a member of a health care network were excluded ( n = 163,998 patients) because we wanted to examine only the role of network structures on outcomes; this resulted in a cohort of 359,144 patients. Hospital network centralization, which was defined as the percentage of total network cases performed at the highest volume hospital and categorized into quartiles (eg, lowest 25% of networks by concentration, 26%–50% of networks by concentration, etc). Primary outcomes included postoperative 90-day complications, 90-day readmissions, and 1-year revisions. Multivariable logistic and linear regressions evaluated associations of hospital network centralization with outcomes and controlled for relevant patient-level and hospital-level covariates, including hospital network volumes. Results: Odds of 90-day complications were lower in the most centralized hospital networks than in least centralized networks (odds ratio [OR] = 0.85; 95% confidence interval [CI]: 0.75, 0.95). Degree of centralization was not associated with readmissions or 1-year revision rates. Non-modifiable patient and individual hospital characteristics appeared to have a greater association with complications, readmissions, and early revision rates than hospital network centralization or volume. Conclusion: This retrospective database study found that increased centralization of primary TJA within a hospital network was associated with lower 90-day complication rates but not with 90-day readmission or 1-year revision rates. This suggests that structural changes within hospital networks may be beneficial to reduce early complications in this patient population. In addition, our findings suggest that risk adjustment in assessing non-modifiable patient and hospital risk factors may be important when assessing TJA outcomes.

Evolving Patterns in Inpatient Pediatric Consultations to Allergy/Immunology at an Academic Medical Center

Background: Consultations to pediatric allergy/immunology are of benefit to many hospitalized inpatients, but there is limited current information about how T-cell receptor excision circles (TREC) screening may have changed these patterns for pediatric populations. We aimed to determine the types of consults being requested and their relative frequencies for primary pediatric allergy/immunology consults under an academic fellowship program since the start of TREC screening in 2016. Information gained could help identify focal concepts for pediatric allergy inpatient training curricula for fellowship and graduate medical education programs. Methods: Under an IRB approved study of an academic allergy fellowship consultation log, we retrospectively reviewed electronic medical records of pediatric allergy and immunology consults and categorized consultations by their primary indication. Results: Three-hundred and eighty-three pediatric allergy/immunology consultations were seen between September 4, 2016 to November 24, 2022. In terms of frequency, the most common consultation was for immunodeficiency evaluation or treatment, n=205 (53.5%), followed by drug allergy n=55 (14.4%), general allergy concerns n=43 (11.2%), skin allergy n=35 (9.1%), and less commonly inflammatory syndromes, n=26 (6.8%) and food allergy, n=19 (5.0%). Questions related to TREC screening comprised 21% of all immunodeficiency consults, at n=43. Conclusion: At an academic allergy center where all allergy/immunology service lines are currently provided, the most common reason for pediatric consultations were for help with immunodeficiency evaluation/treatment and drug allergy. TREC screening is a new key indication for consultation. Fellowship programs may benefit from focusing on these content areas for the pediatric inpatient setting.

Quality Improvement Assessment of Massive Transfusion Protocol (MTP) Utilization and Blood Component Return to Blood Bank in a Level 1 Trauma Center

Abstract Introduction/Objective The goal of MTP in management of patients with hemorrhage is to restore coagulation factors, oxygen carrying capacity, and platelets by transfusing equal amount of plasma, RBC, and platelets. Upon activation of MTP, blood components are released in rounds until deactivation. This quality improvement study was initiated to assess blood products transfused versus returned during MTP activation at our Level1 Trauma Medical Center. Methods/Case Report Upon MTP activation, the Blood Bank (BB) prepares first round of cooler with components at 5:5:1 ratio of plasma, RBC, apheresis platelets. We reviewed retrospective MTP data of eleven-month, from 10/2022- 08/2023. We analyzed patterns of blood component usage by service line, number of MTP rounds issued, and number of units transfused versus returned. Results (if a Case Study enter NA) MTP data was reviewed for 195 patients. MTP activation by service line included emergency department 58.5%, medical ICU (MICU) 14.4%, and surgical ICU (SICU) 11.8%. In many MTP activations, only one round of components was released. Overall, an average of 1.5 rounds were issued. Data of units transfused and returned by component type showed more RBC (43.1%) units were transfused than plasma (39.4%) suggesting MTP transfusion did not follow 1:1:1 ratio. Out of all issued blood units 58% were returned. The high fraction of returned blood components suggests MTP activation may not always truly indicate massive hemorrhage. This finding, and the notable frequency of MTP activation for MICU and SICU patients suggests that individual component order on an emergency-release basis may have been the appropriate option. Conclusion In general, the data suggests implementation of a quality improvement initiative focused on increasing awareness of criteria for MTP activation, and training of staff surrounding MTP is essential. We recently implemented an electronic emergency transfusion order set that allows providers to order individual components for non-massively bleeding patients.

Temnikovskaya Zaseka: Border Service and Frontier Line in the Defense System of the “Ukraine” of the Russian State in the 16th – First Third of the 18th Century

Temnikovskaya Zaseka: Border Service and Frontier Line in the Defense System of the “Ukraine” of the Russian State in the 16th – First Third of the 18th Century

Assessing the sustainability and safety of Polyethylene Terephthalate (PET) liners for Lead Service Lines (LSL) Upgrades

Polyethylene Terephthalate (PET) liners have been proposed by industry as a more cost effective and less disruptive alternative to lead service lines (LSL) replacement. However, concerns have been raised about their aging under real-use conditions and their potential health and environmental impacts. In this study, two approaches were implemented. First, bench and pilot scale experiments were carried out to investigate the aging of a PET liner under conditions that simulate normal usage. Results show early surface oxidation and leaching of potentially hazardous metals (lead, zinc and titanium). No short-term fragmentation of the PET liner into microplastics was observed. Next, a life cycle assessment (LCA) compared the health and environmental impacts of three LSL upgrades alternatives: PET liners and full LSL replacement using either copper or PEX pipes. The installation phase was shown to be the main contributor to impact scores, while the benefits of PET liners are highly dependent on its lifespan. PEX installed by torpedoing lowers impacts as compared to PET liners and copper pipes for equal lifespan, while the use of PET liners remains less impactful regarding human health and ecosystem quality when a complete excavation is needed. LCA derived global human health effects due to ingestion of leached metals from PET liners, copper pipes, and unreplaced LSL and showed that PET liners and copper pipes significantly reduce health impacts by 14 and 80 DALY respectively compared to unreplaced LSL. Finally, the Integrated Exposure Uptake Biokinetic (IEUBK) model was used to assess the impact of lead exposure specifically for drinking water ingestion. Estimated Blood Lead Levels (BLL) in children and infants in households with long unreplaced LSL was up to 263.7% and 207.8% greater compared to either replacement with copper pipes or rehabilitation with PET liners, showing the clear benefits of corrective action. Combining experimental results, LCA and biokinetic modelling provides actionable information for utilities to select the best upgrade options, considering environmental, health and practical constraints, whilst identifying remaining data gaps. The relative benefits of the PET liner should be carefully evaluated considering its lifespan under real-life conditions, the complete replacement costs after failure, and the growing evidence of micro- and nanoplastics (MNP) risks.

Implementing continuous improvement processes in oil and gas operations: A model for enhancing product service line performance

In the dynamic and highly competitive oil and gas industry, operational efficiency and performance are critical to sustaining growth and profitability. Continuous improvement processes are essential for enhancing Product Service Line (PSL) performance, driving operational excellence, and maintaining a competitive edge. This review presents a comprehensive model for implementing continuous improvement processes specifically tailored for the oil and gas sector, focusing on optimizing PSL performance. The proposed model integrates key principles of continuous improvement, including incremental changes, feedback loops, and iterative enhancements, within the context of the oil and gas industry's unique operational environment. It outlines a systematic framework for defining objectives, setting performance metrics, and identifying areas for improvement. The model emphasizes the importance of establishing a dedicated continuous improvement team, providing targeted training, and developing robust processes for ongoing monitoring and evaluation. The review highlights various tools and techniques, such as Lean principles, Six Sigma methodologies, and Root Cause Analysis (RCA), which are pivotal in identifying inefficiencies, reducing waste, and enhancing the overall quality of PSL operations. By incorporating these tools, organizations can achieve significant advancements in operational performance and cost-effectiveness. Case studies from industry leaders are examined to illustrate successful implementations of the continuous improvement model and to derive lessons learned. These case studies provide valuable insights into effective strategies and highlight the impact of continuous improvement on PSL performance. Challenges associated with implementing continuous improvement in the oil and gas sector are also addressed. Issues such as resistance to change, resource constraints, and difficulties in measurement are discussed, along with proposed solutions including change management strategies, efficient resource allocation, and the development of robust measurement systems. The review concludes by exploring future directions for continuous improvement in oil and gas operations, considering emerging technological trends and the integration of digital transformation initiatives. Recommendations for ongoing improvement are provided, emphasizing the importance of continuous feedback loops and adaptability to evolving industry standards. This model serves as a strategic guide for oil and gas organizations seeking to enhance their PSL performance through systematic and sustained continuous improvement efforts, ultimately contributing to their long-term success and operational excellence.

National Service Line for Incarcerated Survivors of Sexual Abuse Program (DOJ)

National Service Line for Incarcerated Survivors of Sexual Abuse Program (DOJ)

Impact of implementing primary care-based medication for opioid use disorder on provider and staff perceptions

Abstract Medication for opioid use disorder (MOUD) is the management of opioid use disorder (OUD) on an outpatient basis with buprenorphine or buprenorphine/naloxone (or methadone, which is limited to federally certified opioid treatment programs). Primary care practices are well poised to provide comprehensive care for patients with OUD, including provision of MOUD. The aim of this study was to assess provider and staff OUD attitudes and role perceptions before and after implementation of a MOUD clinical service line. A survey was distributed to evaluate attitudes and perceptions of patients with OUD and provision of MOUD among providers and staff in an academic family medicine clinic. Surveys were distributed in December 2020 (73% response rate), prior to a substance use disorder educational training and MOUD service line implementation, which provided patients with OUD both primary care services and management with buprenorphine/naloxone. A follow-up survey was distributed in February 2022 (69% response rate).Training and implementation of the MOUD service line demonstrated improvements in the domains of motivation (+0.63), attitudes (+0.32), satisfaction (+0.38), role support (+0.48), role adequacy (+0.39), and safety (+0.79) among surveyed participants. The change in satisfaction and safety domains was statistically significant (P < .05). There was no change in the role legitimacy domain.Implementation of a primary care-based MOUD service line positively affected provider and staff motivation, attitudes, satisfaction, sense of safety, role support, and adequacy when working with patients with OUD. This highlights the benefits of MOUD-specific clinical support to optimize care delivery within primary care.

Developing Service Line Inventories: Guidance for Utilities With Limited Lead Lines

Key TakeawaysIn the United States, all community and nontransient noncommunity water systems are required to submit an inventory describing the location and makeup of all service lines in their service areas.While the material can be designated as lead, galvanized requiring replacement, nonlead, or unknown, the last two designations require additional steps to be taken in the proposed Lead and Copper Rule Improvements (LCRI).Some utilities have few or no lead service lines, and this inventory requirement, issued by the US Environmental Protection Agency (EPA), may be burdensome to those utilities.This article demonstrates the methodology in EPA's proposed LCRI for verification of construction material, and an alternate validation procedure is proposed.

Role and Outcomes of Supported Community Living Programs in Post-Hospital Brain Injury Rehabilitation Programs.

(1) To determine the proportion of participants admitted to supported community living (SCL) programs over the course of 5 years who improve, decline, or maintain functioning and community integration and (2) to examine the associations of time since injury, time in program, and age to their functional trajectory. Data from SCL programs serving individuals with acquired brain injury (ABI). 104 individuals with traumatic brain injury (TBI), stroke, or other ABI. Sex, age, time since injury, Mayo-Portland Adaptability Inventory (4th edition; MPAI-4). Retrospective analyses of MPAI-4 total and MPAI-4 indices using Linear Mixed Models (LMM) of Rasch-derived T-scores from admission to 5 years into service delivery. MPAI-4total, index, and subscale scores for yearly intervals of SCL services from admission to 5years showed a high degree of stability in function (defined using the standard error of measurement (SEM) for the MPAI-4, defined as change≥3T-score points) with all intervals showing at least 89% of patients with improved scores or no change. The rate of change over time did not significantly vary by time since injury, time in the program, or age. The expectations for services in the SCL portion of the care continuum for ABI are unique. Unlike intensive rehabilitation programs which focus on improvement often earlier in the course of recovery, the goal of SCL services is sustained functioning over the long term. Analyses reported here indicate this can be achieved for at least 5years, potentially mitigating the increased risk for rehospitalization and increased care needs in the ABI population. This study highlights a key finding of MPAI-4 stability within these understudied brain injury service lines. Additional exploration of comorbidities and more nuanced delineation of diagnostic information could further clarify factors influencing outcome stability over time.

Patient- and Provider-Level Factors Associated with Patient Portal Usage Among Medicaid Recipients.

Background: Patient portals can improve access to electronic health information and enhance patient engagement. However, disparities in patient portal utilization remain, affecting disadvantaged communities disproportionately. This study examined patient- and provider-level factors associated with portal usage among Medicaid recipients in a large federally qualified health center (FQHC) network in Texas. Methods: Deidentified electronic medical records of patients 18 years or older from a large Texas FQHC network were analyzed. The dependent variable was a binary flag indicating portal usage during the study period. Independent variables included patient- and provider-level factors. Patient-level factors included sociodemographic, geographic, and clinical characteristics. Provider characteristics included primary service line, provider type, provider language, and years in practice. Because the analysis was at the individual level, a multivariable logistic regression model focused on adjusted associations between independent variables and portal usage. Results: The analytic sample consisted of 9,271 individuals. Compared with individuals 18-39 years, patients 50 years and older had lower odds (50-64 OR: 0.60, p < 0.001; 65+ OR: 0.51, p < 0.001) of portal usage. Males were less likely to use portals (OR: 0.44, p = 0.03), and compared to Non-Hispanic Whites, Non-Hispanic Black (OR: 0.86, p = 0.02) and Hispanics (OR: 0.83, p < 0.001) were significantly less likely to use portals. Individuals with 1 or more telemedicine consults had a two-times greater odds of portal usage (OR: 1.97, p < 0.001). Compared to individuals who had clinic visits in December 2018, portal usage was significantly higher in the pandemic months (March 2020-November 2020, all p's < 0.01). Importantly, the behavioral health service line had the greatest odds (OR: 1.52, p < 0.001), whereas the dental service line had the lowest odds (OR: 0.69, p = 0.01) compared to family practice. No other provider characteristics were significant. Conclusion: Our finding of significant patient-level factors is important and can contribute to developing appropriate patient-focused health information technology approaches to ensure equitable access and maximize the potential benefits of patient portals in health care delivery.

51505 An investigation of teledermatology trends in the state of Texas: A multicenter retrospective cohort review of an eConsult service line

51505 An investigation of teledermatology trends in the state of Texas: A multicenter retrospective cohort review of an eConsult service line

A high-performance framework to integrate primary care and behavioural health

This paper describes a large statewide initiative in Arizona led by the Arizona Medicaid programme to integrate the delivery of primary care and behavioural services. Healthcare in the USA remains fragmented, as reflected in no small measure by the separation of primary care and mental health services, in both structure and delivery. The fact that this historical separation continues to be perpetuated is detrimental to the goals of the Triple Aim. The fragmentation between both clinical service lines is further compounded by the high rate of co-occurring physical and mental illness, shortage of mental health professionals, under-skilling of primary care providers in the management of mental health, and stigma associated with mental illness. Underserved communities, where trust deficits of healthcare systems are commonplace, are especially vulnerable to the untoward effects of fragmented services. In this paper a framework is described to integrate primary care and behavioural health, implemented as a multi-year, multi-stakeholder programme at microsystem level, with policy implications for improving access, outcomes, costs and disparities.

Estimating the impact of the proposed Lead and Copper Rule Improvements

AbstractLead in drinking water can lead to serious health effects, including neurodevelopmental issues and heart disease. In December 2023, the U.S. Environmental Protection Agency (EPA) proposed the Lead and Copper Rule Improvements (LCRI), which lower the Lead and Copper Rule's (LCR's) lead action level (AL) from 15 parts per billion (ppb) to 10 ppb and require both first‐ and fifth‐liter sampling and 90th percentile compliance calculations based on the highest lead levels at sites with lead service lines. A methodology for estimating the likelihood a system will have an AL exceedance (ALE) under the LCRI was developed using Michigan LCR compliance data and applied to national LCR compliance data. Findings were compared to EPA's estimates, indicating EPA may have underestimated the percent of smaller systems (serving 3300) with ALEs and overestimated the percent of larger systems (serving &gt; 10,000), thus underestimating costs and overestimating the benefits of this rulemaking.

Behind the screen: exploring the effects of home working on 999 telephone clinicians during the COVID-19 pandemic.

The COVID-19 pandemic has significantly stretched global healthcare provisions since its commencement in 2019. From the outset, ambulance services in the UK had to adapt and change their working practices to meet distancing requirements, to increase staff numbers and to ease the effects of staff becoming unavailable for work due to self-isolation and illness. One strategy was moving clinicians from emergency operation centres (EOCs) to working from home. Like many international services, UK ambulance services use paramedics and nurses to undertake telephone and video assessments of patients calling the 999 emergency services line in a model known as virtual care or remote clinical decision making. Virtual care is any interaction between a patient and a clinician or clinicians, occurring remotely via information technologies.Increasing evidence is becoming available to suggest that the pandemic caused harm to the well-being of healthcare workers, primarily due to the severe stress of regular exposure to death and human suffering. However, there remains a dearth of literature focusing on the well-being of remote and virtual clinicians, especially those who moved from working in EOCs to working at home during the COVID-19 pandemic. Therefore, this study reports the findings of a qualitative analysis of these effects from the clinician's perspective. The authors hope that the findings from this study will inform the operating, well-being and leadership practices of those delivering such services. A convenience sample of telephone nurses and paramedics from one UK ambulance service where home working had been implemented were contacted. Fifteen clinicians with recent home-working experience responded to the invitation to participate out of a possible 31 (48%). All participants had previously practised remote assessment from within an EOC. Semi-structured interviews took place via video-conferencing software and were recorded, transcribed and thematically analysed. An inductive approach was taken to generating codes, and both researchers separately read the transcripts before re-reading them, assigning initial themes and determining frequency. Five main themes were discovered, with further associated sub-themes. The main themes were: safety; financial implications; working relationships; home-working environment; and anxiety. Few studies explore remote clinicians' health and well-being. This study identified that home-working clinicians felt that there had been no detrimental impact on their health and well-being because of working from home during the initial phase of the COVID-19 pandemic. While some concerns were raised, these were mitigated through the support that clinicians received at home from family members, as well as from colleagues, some of whom had developed new working relationships. Financial implications appeared to have contributed to some concerns for participants initially, but these had been alleviated quickly despite requiring further exploration of the true financial impact of working from home.

The use of lead isotopes for determining sources of lead in drinking water

AbstractA series of paired samples were analyzed to determine if high‐precision lead isotopic fingerprinting could help identify the source of lead in plumbing materials and drinking water. Samples were obtained of plumbing materials (lead service lines, copper pipe with lead solder, galvanized materials, and brass fixtures) from water utilities across the United States. Lead samples were taken from the material itself, from scales, and in some cases from associated water. The lead samples were analyzed to determine the ratios of the four stable lead isotopes present. The results enabled the identification of relationships between various components and further aided in the identification of the source of lead found in water and in pipe scales. Isotopic fingerprinting, as demonstrated in this study, could be used to determine if a galvanized line is a galvanized line requiring replacement (GRR) under the Lead and Copper Rule Improvements (USEPA, 2023).

51089 A critical assessment of inpatient dermatology service line in the rural United States

51089 A critical assessment of inpatient dermatology service line in the rural United States

Impact of a Multidisciplinary Service Line and Program for Transcatheter Device Closure of the Neonatal Ductus Arteriosus.

Outline a quality initiative establishing an institutional service line for neonatal transcatheter device closure of the patent ductus arteriosus (TDC-PDA). A retrospective descriptive observational study surrounds programmatic approach to TDC-PDA in premature neonates with process measure spanning education, implementation, referral, and post-procedural care. Metrics tracked pre- and post-program creation with statistical analyses performed. Neonatal TDC-PDA referrals increased exponentially since program inception (n = 13 in year prior; n = 42year 1; n = 74year 2), especially in patients weighing less than 1.3kg (12.5%; 55%; 50%), and were associated with an increased procedural success rate (81%; 95%; 99%). Procedural checklist creation decreased procedural "out of isolette" time (median 93min; 59; 52), and procedural-related complication or clinical sequelae (19%; 12%; 4%). A multidisciplinary service line and program dedicated to neonatal TDC-PDA can result in a significant increase in referrals as well as procedural efficacy and safety for this medically fragile population.

Review of historical plumbing codes for lead service line inventories in the United States

ABSTRACT Inventorying and replacing lead service lines (LSLs) is a national priority in the United States (US), with records review conducted as a first step. Among other records, historical plumbing codes can provide cutoff dates for LSL allowance in the US. This work identified and reviewed historical national plumbing codes for mention of lead for drinking water pipe and found that lead pipe was permissible for service lines by the Basic Plumbing Code until 1978, the Uniform Plumbing Code until 1988, and the Southern Standard Plumbing Code until 1977/78. Overall, identifying pertinent code titles over time and obtaining them was challenging because those records were not readily available. Once obtained, interpreting the code language also proved challenging. Terminology initially reflected sanitary systems before drinking water systems were incorporated, and code editions through the years reorganized the content and specific mentions of lead in service lines within text. This review focused on model plumbing codes, which are then adopted at the state or local level, typically with modifications that also need to be understood. Two practical examples of service line inventory development were also summarized. These examples highlighted placing different emphasis on plumbing code review.