Exit block in emergency departments: a rapid evidence review.

BACKGROUND: Exit block (or access block) occurs when 'patients in the ED requiring inpatient care are unable to gain access to appropriate hospital beds within a reasonable time frame'. Exit block is an increasing challenge for Emergency Departments (EDs) worldwide and has been recognised as a major factor in leading to departmental crowding. This paper aims to identify empirical evidence, highlighting causes, effects and strategies to limit exit block. METHODS: A computerised literature search was conducted of English language empirical evidence published between 2008 and 2014 using a combination of terms relating to exit block in ED. RESULTS: 233 references were identified following the computerised search. Of these, 32 empirical articles of varying scientific quality were identified as relevant and results were presented under a number of headings. The majority of studies presented data relating to the impact of exit block on departments, patients and staff. A smaller number of articles evaluated interventions designed to reduce exit block. Evidence suggests that exit block is more likely to occur in more densely populated areas and less likely to occur in paediatric settings. Bed occupancy appears to be associated with exit block. Evidence supporting the impact of initiatives pointed towards increasing workforce and inpatient bed resources within the hospital setting to reduce block. CONCLUSIONS: Further evidence is needed, especially within the NHS setting to increase the understanding around factors that cause exit block, and interventions that are shown to relieve it without compromising patient outcomes

Blotting Method to Determine Oil Content in Mustard Seeds: A Solution to Asymmetries in the Mustard Seed Economy

Determining oil content in mustard seeds is a time consuming and expensive process, often inaccessible to the common farmer. The proposed oil blot methodology has the potential to be used in low income, remote settings as a first estimate of the oil content in the mustard seed crop. Oil blots were formed by pressing oil out of the seed onto an adsorptive surface using a repeatable force from a vise grip. The area of the blots was an indicator of oil content. While the oil blot methodology would not replace industry standard methods such as Soxhlet extraction, it serves as an accessible, non-specialized method to provide a first-estimate result. This was proved using a Pearson Correlation test (r = 0.95) and t-statistic comparison. The positive significance values show a strong, positive linear correlation between oil content and blot areas. It was determined that the ideal tool for the oil blot methodology was a vise grip due to its repeatability, portability, and low bulk cost. The total cost of the kit was $0.90 with low recurring costs. The extreme simplicity, low capital, and operating cost, make the oil blotting method a valuable tool for small mustard seed producers for estimating the fair value of their crop, reducing their potential exploitation by middlemen

Unfolding Elsewheres

"The central inquiry of Velibor Božović’s exhibition starts with a straightforward question addressed to individuals displaced by war in Bosnia and Herzegovina in the 1990s: How did you get here?" -- Publisher's website

Evaluation of Rice-based Alternatives to Titanium Dioxide for Colour-masking in Iron-Fortified Salts

Titanium dioxide (TiO2) is a common whitening agent used in the food industry, used in candies, baked goods and confectionaries. Several food regulatory agencies have banned or severely restricted TiO2 use due to potential carcinogenic/ genotoxicity. Rice starch and rice flour were investigated as alternatives to TiO2, since they are cheap, opaque, white and are widely used in industry. Due to its amorphous granules and resulting low electrostatic forces, the adhesion of rice starch to extruded materials was much weaker than that of TiO2.  Adhesives were synthesized from crosslinking citric acid with rice starch and rice flour through esterification reaction pathways. The results were tested on extruded ferrous fumarate cylinders used in salt fortification and compared with TiO2 was as control. The results show that rice starch as a whitening agent with a modified rice starch adhesive was a promising option for replacing TiO2 as a colour masking/whitening agent. It was observed that higher mass fractions of citric acid in the adhesive produced better results. Rice flour performed comparably to the rice starch in adhesives however, the ease of use was poorer due to higher viscosity and clumping. The cost for using rice starch was a cost-effective alternative to TiO2 as rice starch is a cheaper, widely available food additive

A multi-faceted intervention to implement guideline care and improve quality of care for older people who present to the emergency department with falls

<p>Abstract</p> <p>Background</p> <p>Guidelines recommend that older people should receive multi-factorial interventions following an injurious fall however there is limited evidence that this is routine practice. We aimed to improve the delivery of evidence based care to patients presenting to the Emergency Department (ED) following a fall.</p> <p>Methods</p> <p>A prospective before and after study was undertaken in the ED of a medium-sized hospital in Perth, Western Australia. Participants comprised 313 community-dwelling patients, aged 65 years and older, presenting to ED as a result of a fall. A multi-faceted strategy to change practice was implemented and included a referral pathway, audit and feedback and additional falls specialist staff. Key measures to show improvements comprised the proportion of patients reviewed by allied health, proportion of patients referred for guideline care, quality of care index, all determined by record extraction.</p> <p>Results</p> <p>Allied health staff increased the proportion of patients being reviewed from 62.7% in the before period to 89% after the intervention (P < 0.001). Before the intervention a referral for comprehensive guideline care occurred for only 6/177 (3.4%) of patients, afterwards for 28/136 (20.6%) (difference = 17.2%, 95% CI 11-23%). Average quality of care index (max score 100) increased from 18.6 (95% CI: 16.7-20.4) to 32.6 (28.6-36.6).</p> <p>Conclusions</p> <p>A multi-faceted change strategy was associated with an improvement in allied health in ED prioritizing the review of ED fallers as well as subsequent referral for comprehensive geriatric care. The processes of multi-disciplinary care also improved, indicating improved care received by the patient.</p

Autologous, lentivirus-modified, T-rapa cell “micropharmacies” for lysosomal storage disorders

T cells are the current choice for many cell therapy applications. They are relatively easy to access, expand in culture, and genetically modify. Rapamycin-conditioning ex vivo reprograms T cells, increasing their memory properties and capacity for survival, while reducing inflammatory potential and the amount of preparative conditioning required for engraftment. Rapamycin-conditioned T cells have been tested in patients and deemed to be safe to administer in numerous settings, with reduced occurrence of infusion-related adverse events. We demonstrate that ex vivo lentivirus-modified, rapamycin-conditioned CD4+ T cells can also act as next-generation cellular delivery vehicles—that is, “micropharmacies”—to disseminate corrective enzymes for multiple lysosomal storage disorders. We evaluated the therapeutic potential of this treatment platform for Fabry, Gaucher, Farber, and Pompe diseases in vitro and in vivo. For example, such micropharmacies expressing α-galactosidase A for treatment of Fabry disease were transplanted in mice where they provided functional enzyme in key affected tissues such as kidney and heart, facilitating clearance of pathogenic substrate after a single administration

Growth in Western Australian emergency department demand during 2007–2013 is due to people with urgent and complex care needs

Objectives: To determine the magnitude and characteristics of the increase in ED demand in Western Australia (WA) from 2007 to 2013. Methods: We conducted a population-based longitudinal study examining trends in ED demand, stratified by area of residence, age group, sex, Australasian Triage Scale category and discharge disposition. The outcome measures were annual number and rate of ED presentations. We calculated average annual growth, and age-specific and age-standardised rates. We assessed the statistical significance of trends, overall and within each category, using the Mann–Kendall trend test and analysis of variance ANOVA. We also calculated the proportions of growth in ED demand that were attributable to changes in population and utilisation rate. Results: From 2007 to 2013, ED presentations increased by an average 4.6% annually from 739 742 to 945 244. The rate increased 1.4% from 354.1 to 382.6 per 1000 WA population (P = 0.02 for the trend). The main increase occurred in metropolitan WA, age 45+ years, triage category 2 and 3 and admitted cohorts. Approximately three-quarters of this increase was due to population change (growth and ageing) and one-quarter due to increase in utilisation. Conclusion: Our study reveals a 4.6% annual increase in ED demand in WA in 2007–2013, mostly because of an increase in people with urgent and complex care needs, and not a shift (demand transfer) from primary care. This indicates that a system-wide integrated approach is required for demand management

Selective advantage of mutant stem cells in clonal hematopoiesis occurs by attenuating the deleterious effects of inflammation and aging

Clonal hematopoiesis (CH) arises when hematopoietic stem cells (HSC) acquire mutations in genes, including DNMT3A and TET2, conferring a competitive advantage through a mechanism that remains unclear. To gain insight into how CH mutations enable gradual clonal expansion, we used single-cell multi-omics with high-fidelity genotyping on CH bone marrow samples. Most of the selective advantage of mutant cells occurs within HSCs. DNMT3A and TET2-mutant clones expand further in early progenitors, while TET2 mutations accelerate myeloid maturation in a dose-dependent manner. Unexpectedly, both mutant and non-mutant HSCs from CH samples are enriched for inflammatory and aging transcriptomic signatures, compared to HSC from non-CH samples, revealing a non-cell autonomous mechanism. However, DNMT3A and TET2-mutant HSCs have an attenuated inflammatory response relative to wild-type HSCs within the same sample. Our data support a model whereby CH clones are gradually selected because they are more resistant to the deleterious impact of inflammation and aging

The impact of early emergency department allied health intervention on admission rates in older people: a non-randomized clinical study

<p>Abstract</p> <p>Background</p> <p>This study sought to determine whether early allied health intervention by a dedicated Emergency Department (ED) based team, occurring before or in parallel with medical assessment, reduces hospital admission rates amongst older patients presenting with one of ten index problems.</p> <p>Methods</p> <p>A prospective non-randomized trial in patients aged sixty five and over, conducted in two Australian hospital EDs. Intervention group patients, receiving early comprehensive allied health input, were compared to patients that received no allied health assessment. Propensity score matching was used to compare the two groups due to the non-randomized nature of the study. The primary outcome was admission to an inpatient hospital bed from the ED.</p> <p>Results</p> <p>Of five thousand two hundred and sixty five patients in the trial, 3165 were in the intervention group. The admission rate in the intervention group was 72.0% compared to 74.4% in the control group. Using propensity score probabilities of being assigned to either group in a conditional logistic regression model, this difference was of borderline statistical significance (<it>p </it>= 0.046, OR 0.88 (0.76-1.00)). On subgroup analysis the admission rate in patients with musculoskeletal symptoms and angina pectoris was less for those who received allied health intervention versus those who did not. This difference was significant.</p> <p>Conclusions</p> <p>Early allied health intervention in the ED has a significant but modest impact on admission rates in older patients. The effect appears to be limited to a small number of common presenting problems.</p