The Emergency Department: Rising wait times, costs, and possible remedies

Emergency Departments (EDs) and Emergency Rooms (ERs) are designed to manage trauma, respond to disasters, and serve as the initial care for those with serious illnesses. However, because of many factors, the ED has become the doorway to the hospital and a “catch-all net” for patients including those with non-urgent needs. This increase in the population in the ED has lead to an increase in wait times for patients. It has been well documented that there has been a constant and consistent rise in the number of patients that frequent the ED (National Center for Health Statistics, 2002); the wait time for patients in the ED has increased (Pitts, Niska, Xu, & Burt, 2008); and the cost of the treatment in the ER has risen (Everett Clinic, 2008). Because the ED was designed to treat patients who need quick diagnoses and may be in potential life-threatening circumstances, management of time can be the ultimate enemy. If a system was implemented to decrease wait times in the ED, decrease the use of ED resources, and decrease costs endured by patients seeking care, better outcomes for patients and patient satisfaction could be achieved. The goal of this research was to explore potential changes and/or alternatives to relieve the burden endured by the ED. In order to explore these options, data was collected by conducting one-on-one interviews with seven physicians closely tied to a Level 1 ED (Emergency Room physicians, Trauma Surgeons and Primary Care physicians). A qualitative analysis was performed on the responses of one-on-one interviews with the aforementioned physicians. The interviews were standardized, open-ended questions that probe what makes an effective ED, possible solutions to improving patient care in the ED, potential remedies for the mounting problems that plague the ED, and the feasibility of bringing Primary Care Physicians to the ED to decrease the wait times experienced by the patient. From the responses, it is clear that there needs to be more research in this area, several areas need to be addressed, and a variety of solutions could be implemented. The most viable option seems to be making the ED its own entity (similar to the clinic or hospital) that includes urgent clinics as a part of the system, in which triage and better staffing would be the most integral part of its success.^

Homeless access to dental health care: Creation of a dental service model

This project involved developing a model for planning a dental emergency treatment center that could function as an embedded component of a shelter for the homeless population. The dental services provided by such a clinic should include treatment for tooth pain, dental caries or cavities, chipped or broken teeth, broken partials, abscessed teeth, emergency cleanings, periodontal disease or gum disease and fillings. These are the dental services that are most often sought by homeless people in hospital emergency rooms.^ The underlying assumption for this project was that the oral health needs of the homeless community can most effectively be addressed by implementing small dental clinics in existing facilities that provide shelter and other services for this population. The model described in this project identifies oral health care services that would be provided by the clinic, facility (physical plant) requirements and associated infrastructure to operate an embedded dental clinic, methods for obtaining funding, strategies of recruiting dental professionals to staff the facility, and methods to assess the outcomes of the embedded clinic strategy. As an example, this project describes a strategy for developing such an embedded clinic at San Antonio Metropolitan Ministries SAMM shelter based on recommendations from community health care leaders, managers of homeless shelters, members of the homeless community and dental professionals^

Fecal coliform contamination in child day care environments in Houston, Texas

Outbreaks of diarrhea are common among children in day care centers (DCC). Enteropathogens associated with these outbreaks are spread by the fecal-oral route through contaminated hands or environmental objects. This prospective study was undertaken to determine the prevalence of fecal coliform (FC) contamination in the DCC environment. Ten rooms in 6 DCC housing 121 children $<$2 years of age were studied for 13 weeks. Inanimate objects (1275), toy balls (724), and hands (954) were cultured 1-3 times per week. FC contamination was common during each week of study and was significantly (p $<$ 0.05) greater for objects, toy balls, and hands of children in toddler compared to infant rooms. In 5 rooms in which clothes were worn over diapers, there was a significantly lower prevalence of FC of toy balls (p $<$ 0.005), inanimate objects (p $<$ 0.05), and hands of children (p $<$ 0.001) and caregivers (p $<$ 0.05) when compared to rooms in which overclothes were not worn. Occurrence of diarrhea was significantly associated with increased contamination of caregivers' and children's hands. Using plasmid analysis of trimethoprim (TMP)-resistant Escherichia coli, stool and environmental isolates from individual DCC rooms had the same plasmid patterns, which were unique to each center. In summary, FC of environmental isolates and hands of children and caregivers in DCC is common; toy balls can serve as sentinels of contamination; FC can be significantly decreased by use of clothes worn over diapers; and plasmid analysis of E. coli strains showed the same patterns from stool and environmental isolates. ^

TRANSMISSION DYNAMICS OF ENTERIC BACTERIA IN DAY-CARE CENTERS, HOUSTON, TEXAS

An investigation was undertaken to evaluate the role of fomites in the transmission of diarrhea in day-care centers (DCC) and to elucidate the paths by which enteric organisms spread within this setting.^ During a nine-month period (December 1980-August 1981) extensive culturing of inanimate objects, as well as children and staff was done routinely each month and again repeated during diarrhea outbreaks. Air was sampled from the classrooms and toilets using a Single-Stage Sieve Sampler (Ross Industries, Midland, VA.). Stool samples were collected from both ill and well children and staff in the affected rooms only during outbreaks. Environmental samples were processed for Shigella, salmonella and fecal coliforms while stools were screened for miscellaneous enteropathogens.^ A total of 11 outbreaks occurred in the 5 DCC during the study period. Enteric pathogens were recovered in 7 (64%) of the outbreaks. Multiple pathogens were identified in 3 outbreaks. The most frequently identified pathogen in stools was Giardia lamblia which was recovered in 5 (45%) of the outbreaks. Ten of the 11 (91%) outbreaks occurred in children less than 12 months of age.^ Environmental microbiology studies together with epidemiologic information revealed that enteric organisms were transmitted from person-to-person. On routine sampling, fecal coliforms were most frequently isolated from tap handles and diaper change areas. Contamination with fetal coliforms was wide-spread during diarrhea outbreaks. Fecal coliforms were recovered with significantly greater frequency from hands, toys and other classroom objects during outbreaks than during non-outbreak period. Salmonella typhimurium was recovered from a table top during an outbreak of Salmonellosis. There was no association between the level of enteric microbial contamination in the toilet areas and the occurrence of outbreaks. No evidence was found to indicate that enteric organisms were spread by the airborne route via aerosols.^ Toys, other classroom objects and contaminated hands probably play a major role in the transmission of enteropathogens during day-care center outbreaks. The presence of many enteric agents in the environment undoubtedly explains the polymicrobial etiology of the day-care center associated diarrhea outbreaks. ^

Internet sex among non-gay identifying men who have sex with men

The aim of this study was to examine the role of the Internet in Internal Homonegativity (IH) among Non gay identifying men who have sex with men (NGI-MSM). This study at University of Texas School of Public Health (UTSPH) had a mixed method research design and consisted of men 18 years of age and older who were residents of the US and Canada. The data were collected using an online survey called 'Men's Sexual Health Survey' which was developed in collaboration with Boston University School of Public Health and Denver Public Health. These surveys were administered in English, which took 30-minutes to complete, and were placed on gay oriented websites and chat rooms. 141 participants were presented with the module relating to IH. A Principal Component Analysis with varimax rotation on the nine questions that asked the participants about their feelings about gay men produced three factors of IH identified as (1) public identification as gay; (2) perception of stigma associated with being gay; and (3) social comfort with gay men. The factors significantly correlated with age, grade completed in school, income, openness about being gay and socializing with gay people, meeting partners online, dating on the Internet, attitude toward condom usage, alcohol and drug use before sex and having unprotected sex with Internet partners. These findings point toward the role of the Internet in determining IH and sexual behavior. Despite the risks, the Internet's popularity and outreach in NGI-MSM makes it an effective medium to spread public health programs.^

Grazing rate of microzooplankton measured experimentally in the North Atlantic during the Maria S. Merian cruise MSM26, spring 2013

The microzooplankton grazing dilution experiments were conducted at stations 126, 127, 131 and 133-137, following Landry & Hassett (1982). Seawater samples (whole seawater - WSW) were taken via Niskin bottles mounted on to a CTD Rosette out of the chlorophyll maximum at each station. Four different dilution levels were prepared with WSW and GF/F filtered seawater - 100% WSW, 75% WSW, 50% WSW and 25% WSW. The diluted WSW was filled in 2.4 L polycarbonate bottles (two replicates for every dilution level). Three subsamples (250 - 500 mL depending on in situ chlorophyll) of the 100% WSW were filtered on to GF/F filters (25 mm diameter) and chlorophyll was extracted in 5 mL 96% ethanol for 12-24 hours. Afterwards it was measured fluorometrically before and after the addition of HCl with a Turner fluorometer according to Jespersen and Christoffersen (1987) on board of the ship. In addition, one 250 mL subsample of the 100% WSW was fixed in 2% Lugol (final concentration), to determine the microzooplankton community when back at the Institute for Hydrobiology and Fisheries Science in Hamburg. Also, one 50 mL subsample of the 100% WSW was fixed in 1 mL glutaraldehyde, to quantify bacteria abundance. The 2.4 L bottles were put in black mesh-bags, which reduced incoming radiation to approximately 50% (to minimize chlorophyll bleaching). The bottles were incubated for 24 hours in a tank on deck with flow-through water, to maintain in situ temperature. An additional experiment was carried out to test the effect of temperature on microzooplankton grazing in darkness. Therefore, 100% WSW was incubated in the deck tank and in two temperature control rooms of 5 and 15°C in darkness (two bottles each). The same was done with bottles where copepods were added (five copepods of Calanus finmarchicus in each bottle; males and females were randomly picked and divided onto the bottles). In addition, two 100% WSW bottles with five copepods each were incubated at in situ temperature at 100% light level (without mesh-bags). All experiments were incubated for 24 hours and afterwards two subsamples of each bottle were filtered on to GF/F filters (25 mm diameter); 500 - 1000 mL depending on in situ chlorophyll. One 250 mL subsample of one of the two replicates of each dilution level and each additional experiment (temperature and temperature/copepods) was fixed in 5 mL lugol for microzooplankton determination. One 50 mL subsample of one of the two 100% WSW bottles as well as of one of the additional experiments without copepods was fixed in 1 mL glutaraldehyde for bacteria determination later on. Copepods were fixed in 4% formaldehyde for length measurements and sex determination.

Pulperos y pulperías rurales bonaerenses : Su influencia en la campaña y los pueblos, 1780-1820

En las últimas décadas se ha construido una nueva imagen del mundo rural pampeano que ha complejizado el análisis con nuevos temas, métodos y fuentes. En estos estudios si bien los pulperos y pulperías están presentes siempre figuran de manera lateral o complementaria. En este trabajo me propuse profundizar el estudio de pulperos y pulperías rurales una vez reconocida su influencia en materia económica, política y social tanto en la campaña en su conjunto como hacia el interior de los pueblos. El tema elegido entonces responde a la necesidad de un estudio exclusivo y exhaustivo sobre un grupo que entendemos ha cumplido una función muy relevante como elemento central en la expansión, ocupación y estructuración de la sociedad rural bonaerense al igual que lo fueron las estancias, los fuertes y las parroquias. La expansión y consolidación de la campaña bonaerense ha sido acompañada por el despliegue comercial en las últimas décadas del siglo XVIII. Podemos hablar de un fenómeno de retroalimentación entre comerciantes y explotaciones ganaderas protagonizado con frecuencia por las mismas personas. En este sentido las pulperías contribuyeron a la formación de pueblos, la ocupación de nuevas tierras y el desarrollo de relaciones pacíficas con los pueblos originarios, aunque a veces fueron agentes disruptores. Nos queda claro que las pulperías eran engranajes importantes dentro de la economía local y ubicaban a sus propietarios por encima de la mayoría de los productores. Sin embargo muchos pulperos también eran productores o viceversa y esa diversificación les permitía disminuir los riesgos y las posibilidades de "naufragio". Creemos haber matizado y en algunos casos rechazado algunas de las imágenes literarias que en general configuraron una visión muy negativa de los pulperos y sus negocios. El pulpero no era muy distinto a su clientela y formaba parte de las costumbres predominantes de la campaña más allá de tener, en muchos casos, una posición económica más holgada. En este sentido, muchos pulperos fueron vecinos referentes en sus pueblos cumpliendo distintas funciones más allá de la fundamental que era el abastecimiento de bienes básicos, ocuparon cargos en el andamiaje institucional y se erigieron en la "voz del pueblo". La posición privilegiada de algunos pulperos les permitía evadir el peso de la justicia y cuando ocupaban cargos sacar provecho de ellos. Esto refuerza la idea de connivencia entre comercializadores locales y el aparato institucional local en torno al usufructo del tráfico de cueros que cada vez se hacía más rentable.

Aspectos de la tradición clásica en América : Sibilas y Triunfos en La Casa del Deán de Puebla de los Ángeles (México)

Dentro de la pintura mural civil mexicana del siglo XVI, ubicamos dos anónimas series iconológicas en dos habitaciones de la Casa del Deán de la ciudad de Puebla: Sibilas y Triunfos realizadas en 1580. Analizamos la posible procedencia del modelo sibilino, su número, particularidades, la composición de la serie y los problemas que presenta. Seguimos el mismo procedimiento para los Triunfos, cuya fuente literaria son los Trionfi de F. Petrarca; otro elemento a considerar son las guardas o cenefas que enmarcan cada serie con flora y fauna tropical americana. Concluimos con el tipo de síntesis plástica lograda

Pulperos y pulperías rurales bonaerenses : Su influencia en la campaña y los pueblos, 1780-1820

En las últimas décadas se ha construido una nueva imagen del mundo rural pampeano que ha complejizado el análisis con nuevos temas, métodos y fuentes. En estos estudios si bien los pulperos y pulperías están presentes siempre figuran de manera lateral o complementaria. En este trabajo me propuse profundizar el estudio de pulperos y pulperías rurales una vez reconocida su influencia en materia económica, política y social tanto en la campaña en su conjunto como hacia el interior de los pueblos. El tema elegido entonces responde a la necesidad de un estudio exclusivo y exhaustivo sobre un grupo que entendemos ha cumplido una función muy relevante como elemento central en la expansión, ocupación y estructuración de la sociedad rural bonaerense al igual que lo fueron las estancias, los fuertes y las parroquias. La expansión y consolidación de la campaña bonaerense ha sido acompañada por el despliegue comercial en las últimas décadas del siglo XVIII. Podemos hablar de un fenómeno de retroalimentación entre comerciantes y explotaciones ganaderas protagonizado con frecuencia por las mismas personas. En este sentido las pulperías contribuyeron a la formación de pueblos, la ocupación de nuevas tierras y el desarrollo de relaciones pacíficas con los pueblos originarios, aunque a veces fueron agentes disruptores. Nos queda claro que las pulperías eran engranajes importantes dentro de la economía local y ubicaban a sus propietarios por encima de la mayoría de los productores. Sin embargo muchos pulperos también eran productores o viceversa y esa diversificación les permitía disminuir los riesgos y las posibilidades de "naufragio". Creemos haber matizado y en algunos casos rechazado algunas de las imágenes literarias que en general configuraron una visión muy negativa de los pulperos y sus negocios. El pulpero no era muy distinto a su clientela y formaba parte de las costumbres predominantes de la campaña más allá de tener, en muchos casos, una posición económica más holgada. En este sentido, muchos pulperos fueron vecinos referentes en sus pueblos cumpliendo distintas funciones más allá de la fundamental que era el abastecimiento de bienes básicos, ocuparon cargos en el andamiaje institucional y se erigieron en la "voz del pueblo". La posición privilegiada de algunos pulperos les permitía evadir el peso de la justicia y cuando ocupaban cargos sacar provecho de ellos. Esto refuerza la idea de connivencia entre comercializadores locales y el aparato institucional local en torno al usufructo del tráfico de cueros que cada vez se hacía más rentable.

Aspectos de la tradición clásica en América : Sibilas y Triunfos en La Casa del Deán de Puebla de los Ángeles (México)

Dentro de la pintura mural civil mexicana del siglo XVI, ubicamos dos anónimas series iconológicas en dos habitaciones de la Casa del Deán de la ciudad de Puebla: Sibilas y Triunfos realizadas en 1580. Analizamos la posible procedencia del modelo sibilino, su número, particularidades, la composición de la serie y los problemas que presenta. Seguimos el mismo procedimiento para los Triunfos, cuya fuente literaria son los Trionfi de F. Petrarca; otro elemento a considerar son las guardas o cenefas que enmarcan cada serie con flora y fauna tropical americana. Concluimos con el tipo de síntesis plástica lograda

Aspectos de la tradición clásica en América : Sibilas y Triunfos en La Casa del Deán de Puebla de los Ángeles (México)

Dentro de la pintura mural civil mexicana del siglo XVI, ubicamos dos anónimas series iconológicas en dos habitaciones de la Casa del Deán de la ciudad de Puebla: Sibilas y Triunfos realizadas en 1580. Analizamos la posible procedencia del modelo sibilino, su número, particularidades, la composición de la serie y los problemas que presenta. Seguimos el mismo procedimiento para los Triunfos, cuya fuente literaria son los Trionfi de F. Petrarca; otro elemento a considerar son las guardas o cenefas que enmarcan cada serie con flora y fauna tropical americana. Concluimos con el tipo de síntesis plástica lograda

Pulperos y pulperías rurales bonaerenses : Su influencia en la campaña y los pueblos, 1780-1820

En las últimas décadas se ha construido una nueva imagen del mundo rural pampeano que ha complejizado el análisis con nuevos temas, métodos y fuentes. En estos estudios si bien los pulperos y pulperías están presentes siempre figuran de manera lateral o complementaria. En este trabajo me propuse profundizar el estudio de pulperos y pulperías rurales una vez reconocida su influencia en materia económica, política y social tanto en la campaña en su conjunto como hacia el interior de los pueblos. El tema elegido entonces responde a la necesidad de un estudio exclusivo y exhaustivo sobre un grupo que entendemos ha cumplido una función muy relevante como elemento central en la expansión, ocupación y estructuración de la sociedad rural bonaerense al igual que lo fueron las estancias, los fuertes y las parroquias. La expansión y consolidación de la campaña bonaerense ha sido acompañada por el despliegue comercial en las últimas décadas del siglo XVIII. Podemos hablar de un fenómeno de retroalimentación entre comerciantes y explotaciones ganaderas protagonizado con frecuencia por las mismas personas. En este sentido las pulperías contribuyeron a la formación de pueblos, la ocupación de nuevas tierras y el desarrollo de relaciones pacíficas con los pueblos originarios, aunque a veces fueron agentes disruptores. Nos queda claro que las pulperías eran engranajes importantes dentro de la economía local y ubicaban a sus propietarios por encima de la mayoría de los productores. Sin embargo muchos pulperos también eran productores o viceversa y esa diversificación les permitía disminuir los riesgos y las posibilidades de "naufragio". Creemos haber matizado y en algunos casos rechazado algunas de las imágenes literarias que en general configuraron una visión muy negativa de los pulperos y sus negocios. El pulpero no era muy distinto a su clientela y formaba parte de las costumbres predominantes de la campaña más allá de tener, en muchos casos, una posición económica más holgada. En este sentido, muchos pulperos fueron vecinos referentes en sus pueblos cumpliendo distintas funciones más allá de la fundamental que era el abastecimiento de bienes básicos, ocuparon cargos en el andamiaje institucional y se erigieron en la "voz del pueblo". La posición privilegiada de algunos pulperos les permitía evadir el peso de la justicia y cuando ocupaban cargos sacar provecho de ellos. Esto refuerza la idea de connivencia entre comercializadores locales y el aparato institucional local en torno al usufructo del tráfico de cueros que cada vez se hacía más rentable.

Qualitative behaviour of L1 and L2 standard deviation in insulations measurements according to standard UNE EN ISO 140-4

Knowledge of the uncertainty of measurement of testing results is important when results have to be compared with limits and specifications. In the measurement of sound insulation following standards UNE EN ISO 140-4 the uncertainty of the final magnitude is mainly associated to the average sound pressure levels L1 and L2 measured. A parameter that allows us to quantify the spatial variation of the sound pressure level is the standard deviation of the pressure levels measured at different points of the room. In this work, for a wide number of measurements following standards UNE EN ISO 140-4 we analyzed qualitatively the behaviour of the standard deviation for L1 and L2. The study of sound fields in enclosed spaces is very difficult. There are a wide variety of rooms with different sound fields depending on factors as volume, geometry and materials. In general, we observe that the L1 and L2 standard deviations contain peaks and dips independent on characteristics of the rooms at single frequencies that could correspond to critical frequencies of walls, floors and windows or even to temporal alterations of the sound field. Also, in most measurements according to UNE EN ISO 140-4 a large similitude between L1 and L2 standard deviation is found. We believe that such result points to a coupled system between source and receiving rooms, mainly at low frequencies the shape of the L1 and L2 standard deviations is comparable to the velocity level standard deviation on a wall

Service needs forecasting: an approach for the automotive industry using analogies with medical ER management models.

During the past years, the industry has shifted position and moved towards “the luxury universe” whose customers are demanding, treating individuals as unique and valued customer for the business, offering vehicles produced with the state of the art technologies and implementing the highest finishing standards. Due to the competitive level in the market, car makers enable processes which equalizes customer services to E.R. management, being dealt with the maximum urgency that allows the comparison between both, car workshops and emergency rooms, where workshop bays or ramps will be equal to emergency boxes and skilled technicians are equivalent to the health care specialist, who will carry out tests and checks prior to afford any final operation, keeping the “patient” under control before it is back to normal utilization. This paper establishes a valid model for the automotive industry to estimate customer service demand forecasting under variable demand conditions using analogies with patient demand models used for the medical ER.

SERVICE NEEDS FORECASTING: An Approach for the Motor Industry Using Analogies with Medical ER Management Models.

During the past years, the industry has shifted position and moved towards “the luxury universe” whose customers are demanding, treating individuals as unique and valued customer for the business, offering vehicles produced with the state of the art technologies and implementing the highest finishing standards. Due to the competitive level in the market, motor makers enable processes which equalizes customer services to E.R. management, being dealt with the maximum urgency that allows the comparison between both, car workshops and emergency rooms, where workshop bays or ramps will be equal to emergency boxes and skilled technicians are equivalent to the health care specialist, who will carry out tests and checks prior to afford any final operation, keeping the “patient” under control before it is back to normal utilization. This paper ratify a valid model for the automotive industry to estimate customer service demand forecasting under variable demand conditions using analogies with patient demand models used for the medical ER