By E. Mitch. Southwest Bible College and Seminary.

He had recently been fred from his factory assembly job because of suspicion of drunkenness order 100 mcg albuterol with amex. Although he denied any signifcant symptoms generic 100mcg albuterol overnight delivery, his wife noted that he was irritable albuterol 100mcg lowest price, slept poorly albuterol 100mcg visa, and was obsessive about his bowel movements, spending hours in the bathroom every day. He had moderate chorea, moderate dysarthria, motor impersistence, and gait instability. He was referred for formal neuropsychological assessment, and met with the social worker to assist with the completion of disability forms. A speech- language pathologist evaluated his swallow function, which was minimally impaired, and the dietician discussed his caloric needs and made recommendations about high calorie foods and nutritional supplements. The man and his wife had not previously met with a genetic counselor, so a genetics consultation was arranged. The physical therapist recommended a daily exercise program to help the man maintain his mobility and balance. The man’s wife was struggling with the situation, as she was also working part-time and caring for the couple’s two children. A follow-up appointment with the doctor was scheduled for one month later, to evaluate the effects of medication changes and ensure that the recommendations of the health team had been well-received. At that time, the man’s wife reported that his irritability was improved, and that he was sleeping better, although he was still somewhat perseverative. After a variety of relationship, fnancial, and legal problems, she visited a psychiatrist, who referred her to a neurologist because of some involuntary movements. The family physician found no evidence of medical disease, despite the woman’s rapid 15 pound weight loss. The neurologist there found abnormal involuntary movements, abnormal saccadic eye movements, impersistence of tongue protrusion, inability to perform a three-step motor command, diffusely brisk refexes, and an erratic lurching gait. No new medications were needed, as the depression and anxiety were, by then, adequately controlled, but benztropine was deemed to be unnecessary and was discontinued. The social worker spoke with the family about applying for Social Security Disability Insurance benefts, as the psychometric testing showed moderate subcortical dementia. The dietician talked with the woman and her family about healthy eating and strategies to increase caloric intake. Six months later, she had successfully qualifed for Social Security Disability Insurance benefts, and had moved into an assisted living facility near her parents. She had completed her Advance Care Directives, and was an active participant in a clinical research study. Her mood had brightened substantially as she now understood the cause of her disabilities. Those who have not stopped driving ft into one of three categories: Those with no discernable problems, those who represent an obvious menace, usually because of a record of prior incidents or grossly impaired judgment, and those about whom the clinician is initially unsure. Uninsightful or desperate individuals may not always be upfront about these issues, and the family can be encouraged to examine the car for dents and scratches and to make sure the insurer has not cancelled the person’s policy. Have they noticed any irregularities such as swerving, errors of judgment, diffculty braking, or uneven pressure on the accelerator? A good rule of thumb is that if a person’s family would not allow him to pick up children from school then he does not belong on the road. Family members may fear the person’s reaction to their opinions and should be given a chance to speak to the physician alone. They may need advice and support to help them feel strong enough to take the necessary steps. Individuals and families should be encouraged to think ahead and develop a plan for driving cessation that addresses questions such as “Is the person living in an accessible area? In life and death matters such as this, the instruction to stop driving is not a recommendation. The physician must be willing to expend considerable emotional goodwill on this issue or even to lose the person from her practice entirely. A recalcitrant individual should be told that the assessment of him as an unsafe driver and the explicit instruction to stop will be entered into his permanent medical record, and that the doctor will not support him if an accident occurs. In especially problematic cases it may be necessary to have the person’s license suspended over his objections, or even to have the car impounded. The doctor’s responsibility regarding unsafe drivers will vary by state, province or country. In some municipalities, physicians are obligated to report individuals who are unsafe to drive because of certain medical conditions or unsafe drivers in general. In other areas, to do so would constitute a breach of doctor/patient confdentiality. Confdentiality is not an absolute right, and it is sometimes trumped by a physician’s duty to the life and safety of the individual and the safety of the public. When there is no other alternative, it may be necessary for a physician to deliberately breach confdentiality to report a person’s behavior to the authorities. The most recognized motor symptom is chorea, but a number of additional movement disorders occur, including dystonia, bradykinesia, rigidity, myoclonus, tics, and tremor.

We are working to make more surveillance tools available to state and local public health personnel and more surveillance information available to public health workers albuterol 100 mcg discount, policy makers and the general public through combined reports and information available on the Internet purchase 100 mcg albuterol visa. The case and isolate counts for eight diseases and pathogens for 2004 are presented in Table 1- 1 and described on the following pages albuterol 100 mcg without prescription. In 2000 buy 100mcg albuterol with amex, the Council for State and Therritorial Epidemiologists passed a resolution in which all Shiga toxin-producing E. The steady increase in the number of cases 6 was due in part to an increasing ability of laboratories to identify this pathogen. Coordinated efforts by regulators and industry have been effective in reducing contamination and illness related to ground beef. The four most common O groups were O26 (19%), O45 (13%), O111 (13%), and O103 (18%). Patients reported in national notifiable diseases surveillance include only those with antecedent diarrheal illness. The most common etiology in the United States is infection with a Shiga toxin-producing E. During 2004, 49 states or territories reported at least one case, for a total of 753 cases. Salmonella Typhi (Typhoid Fever) Infection with Salmonella serotype Typhi leads to typhoid fever. Typhi isolates are reported through the National Salmonellosis Surveillance System; 306 isolates were reported in 2004. Salmonella, Non-Typhi (Salmonellosis) A total of 35,355 non-Typhi Salmonella isolates were reported in 2004. Similar to other years, Salmonella was isolated most frequently from children younger than age 5 years, accounting for 27% of isolates. About 10% of isolates came from persons in each of the second through fifth decades of life, with lower proportions from persons in later decades of life. Since 1995, specific control programs have succeeded in the dramatically reducing Salmonella serotype Enteritidis, which has been associated with the internal contamination of eggs. L(+) tartrate+ (formerly Java), and Javiana, have increased in numbers since 1994. Shigella (Shigellosis) Shigella transmission occurs most commonly via the fecal-oral route. Most Shigella sonnei 7 infections are associated with crowding and poor personal hygiene. The relative proportions of the four different subgroups remained constant, with S. One patient was a Georgia resident who consumed oysters traced to a Florida harvest site. The second patient was a Georgia resident who reported no exposure to seafood before illness. The third patient was an Alabama resident who consumed oysters that could not be traced back to their harvest site. In 2004, 501 other Vibrio isolates from 479 patients were reported to the Cholera and Other Vibrios Surveillance System. Of these 479 patients, 130 (27%) were from Gulf Coast states, 211 (44%) were from Pacific Coast states, 100 (21%) were from Atlantic Coast states (excluding Florida), and 38 (8%) were from inland states. Among patients for whom information was available, 173 (38%) of 460 were hospitalized, and 39 (9%) of 443 died. Only a few select tables and figures, from the Salmonella Annual Summary, 2004, and the Shigella Annual Summary, 2004, are included here. Botulism is a rare but serious paralytic illness caused by a neurotoxin produced by the bacterium Clostridium botulinum. Wound botulism is caused by toxin produced from a wound infected with Clostridium botulinum. Infant botulism is caused by consumption of spores of the Clostridium botulinum organism, which then grow in the intestine of infants and release toxin. Because many people can eat a food contaminated with the botulism toxin, every case of botulism suspected to be foodborne is considered a public health emergency. The request for consultation and release of antitoxin by health departments and physicians is the basis of surveillance for most cases of foodborne and wound botulism. For consultation on suspected infant botulism occurring in any state, the Infant Botulism Treatment and Prevention Program of the California Department of Health Services should be contacted at (510) 231- 7600. Among the 14 cases of foodborne intoxication, toxin type A accounted for 12 (86%) cases and toxin type E for 2 (14%) cases. One was caused by “pruno,” a bootleg prison-made alcoholic beverage, and the other was caused by home-canned mushrooms. Toxin type B accounted for 54 (59%) 9 cases, toxin type A for 36 (40%) cases, and toxin type F for one (1%) case. All 4 patients received cosmetic injections of high-dose, unlicensed botulinum toxin A product not intended for human use.

Smaller instrumentation to exploit the phage infection analytes are accelerated to higher velocities process to intensify a detectable signal that is than larger ones and thus reach the analyser atributable to the presence of the targeted sooner 100mcg albuterol amex. The charge (z) of an ionized molecule generic 100mcg albuterol mastercard, if given a value of 1 cheap albuterol 100mcg without prescription, thus makes the Phage Amplification and m/z value equal to the mass of the molecule buy albuterol 100mcg low cost. In contrast, purified adapted in many formats for detection of a A511 phage yields a mass spectrum consisting large number of analytes and have proven of one main peak representative of a useful for rapid, phage amplification-based previously described 48. Goodridge and Steiner, Chapter 11, this Immediately following infection with phage volume). First described in 1980 and later Bacteriophage-based Methods of Bacterial Detection and Identification 139 (a) (b) Mass (m/z) Mass (m/z) (c) (d) Mass (m/z) Mass (m/z) Fig. The intensity scale is expanded to compensate for a very high concentration of bacterial proteins. Cox developed as a commercial pregnancy test, indicate that the sample was completely the technique was originally termed the ‘sol transported across the detection zone (C on particle immunoassay’ (Leuvering et al. Following incubation, a primary reporter consisting of coloured nanoparticles conjugated to phage-specific (b) antibodies is added to the infection reaction. The secondary reporter and any phage–primary reporter complexes are carried on to a nitrocellulose detection mem- brane striped with a detection line composed Fig. C, control line; T, test line; S, sample streptavidin) and concentrates there, to applicator pad. Afer 5 h incubation, an aliquot of the phage Phages can be atached to a solid surface such infection reaction was applied to the pictured that they can adsorb to their bacterial host handheld cassete on the sample applicator while remaining fixed to that surface. In this pad (S) and allowed to wick across the test way, phages have been used as a species- window. A positive result is indicated by the specific biosorbent to capture or separate formation of two lines – one at the test line T bacteria from liquid samples for further and another at the control line C. The first reported use phage amplification, accompanying control of immobilized phages for bacterial capture tests were run at the same time. The ‘Sapphire’ absence of a false positive, as indicated by the phage was passively atached to microtitre formation of only a single control line. A single test for concentration of bacteria from an over- line in the absence of phage was observed night culture, poor capture efficiency (1%) only at the control line. Phage-coated bacterial identification and antibiotic resist- particles were reacted with overnight cul- ance determination. This led to the founding tures of a bioluminescent lux-expressing of Microphage, Inc. Other approaches involve covalent Phage-encoded Reporter Genes for atachment of Salmonella phages to glass for Bacterial Detection bacterial capture (Handa et al. The later luxA and luxB encode the two-component strain is added in tandem with the re- luciferase holoenzyme responsible for light combinant phage to the test sample. The first bioluminescence in the bacterial reporter description of its use in bacterial detection strain as an indication of the presence of involved insertion of the complete lux operon target E. It has been adapted luxR luxI luxC luxD luxA luxB luxE luxR luxI luxC luxD luxA luxB luxE Fig. Originally isolated from the bio- applications (for example, the Luc-Screen® luminescent hydrozoan jellyfish Aequorea Firefly Luciferase Reporter Gene Assay victoria (Shimomura et al. While dependent on the presence of oxygen As is the case with many lux-based reporter (Heim et al. Several studies aimed at constructs have been engineered to exploit addressing this and improving the target host luc-based bioluminescence with the aim of range followed. While these designed to prevent host-cell destruction studies show promise for mycobacterial (Tanji et al. Using similar approaches, detection, they are still hampered by extensive lytic (Oda et al. It should be noted, Bacteriophage-based Methods of Bacterial Detection and Identification 145 however, that viable cells gave the most multiplexed detection of numerous targets in intense fluorescent signal. Wall-binding Domains Phage-encoded endolysins are peptidoglycan Phage-conjugated hydrolases that serve as one component of Quantum Dots the phage lytic system (Fisheti, 2005). To date, photostability in comparison with con- numerous endolysins have been sequenced, ventional fluorophores, are more reactive purified and applied from without to destroy across a broad spectrum of excitation wave- bacteria and explore their use as potential lengths and fluoresce at narrow, size- alternatives to antibiotics (Loeffler et al. Nevertheless, endolysins over a wide emission bandwidth makes are potentially powerful tools, not only for 146 C. Cox biocontrol but also for highly specific personnel, methods for the use of phage detection. Bacterial recovery rates of greater to quickly and specifically isolate and than 90% were observed following 24 h of concentrate target bacteria for analysis enrichment and 16 h of selective plating of with existing detection instrumentation. Fluorescence-based bacterial detection by targeted infection and delivery of fluorescent reporter systems by recombinant phages Conclusions show great promise as multiplexed bio- luminescent and fluorescent detection tools, Despite the growing need for rapid, and the emerging use of highly refined phage inexpensive methods of bacterial detection endolysins show strong potential in high- and identification, most current methods fall efficiency bacterial capture and identification.

At home the child should ideally sleep in a separate bedroom or bed from susceptible siblings quality albuterol 100 mcg. Soiled tissues should be disposed of straight into a disposal bag where possible albuterol 100mcg mastercard, avoiding the risk of contaminating surfaces or needing to handle secretions purchase albuterol 100mcg visa. Surfaces should be cleaned with a damp cloth and detergent daily to avoid the build up of contamination albuterol 100mcg overnight delivery. Disinfection of surfaces and equipment should be undertaken with a 1 in 10 solution of bleach (hypochlorite). Protective clothing • Where available masks and eye protection should be worn by health care staff where splashing or spraying of secretions into the eyes or mucous membranes of the nose or mouth may occur, e. Module 5 Page 153 General nursing care Appendix 2 Assess respiratory status as per Appendix 3. Physical and psychological rest • Bed rest in a semi-prone position to increase the vital capacity of the lungs and facilitate breathing. Ensure a quiet calm environment, explain procedures as appropriate for the patients age. Management of fever • Ensure adequate fluid intake to prevent dehydration and reduce the symptoms of toxicity. Intravenous or nasogastric fluids may be necessary to prevent electrolyte imbalance and to avoid aspiration of oral fluids during acute respiratory distress. Children 10–15 mg/kg per dose every 4–6 hours or as a general guide: 3 months–1 year: 60–120 mg per dose / 1–5 years : 120–250 mg per dose / 6–12 years : 250– 500 mg per dose. Reduce the ambient room air temperature and improve air circulation by using a fan. If the patient is peripherally shutdown with cold extremities, apply cotton socks/mittens. Nutrition and hydration • A light nourishing diet should be given, nasogastric tube feeding may be necessary. Mothers of breast feeding babies should have the baby rest intermittently during feeding to avoid the aspiration of milk. In infants under one year feel the anterior fontanelle, if it is sunken or depressed this may indicate poor hydration. Page 154 Module 5 General nursing care Appendix 2 (continued) Respiratory care • Keep the nostrils clear of mucous so the child can breathe while sucking and eating; infants are obligatory nose breathers. It can also be administered via nasal prongs or a mask in older patients at approximately 0. Where available the patients oxygen saturations are monitored via a pulse oximiter. At home the room air can be moistened by placing a moist cloth or uncovered pot of water on/near the heater. There may be dryness of the lips due to dehydration or excoriation of the skin around the nose from secretions, apply white soft paraffin. The parents/relatives should seek advice immediately if the patient’s condition deteriorates, i. The patient must be reassessed; the antibiotics may need to be changed and the patient may need admitting to hospital. Module 5 Page 155 Assessing respiratory status in a child Appendix 3 Ask Observe How old is the child? Has the child been sleeping longer Try and count the respiratory rate when the child is calm. Count the respiratory rate before taking temperature or pulse to avoid upsetting the child and affecting the true rate. Faster than 60 per minute in an infant less than 2 months old Has the child had convulsions? Faster than 50 per minute in a child between 2-12 months Faster than 40 per minute in a child between 12 months to 5 years? Auscultation of the chest – note the presence of breath sounds, Has the child been feeding? Guide only Appendix 4 Antibiotic Dose and regime Common side effects/comments Penicillin: Ampicillin 5 days Adults Oral 250 mg–1 g every 6 hours at least 30 minutes Nausea, vomiting, diarrhoea. Children under 10 years, any route, half adult dose Amoxycillin Adults May reduce the effectiveness of oral 5 days Oral 250 mg every 8 hours, doubled in severe contraceptive pill. Intravenously: adult 500 mg–1 g 6 hourly Child 50 mg/kg per day in divided doses every 6 hours. Guide only Appendix 4 (continued) Antibiotic Dose and regime Common side effects/comments Thetracyclines Nausea, vomiting and diarroea. Rashes may Thetracycline Adults 250 mg every 6 hours occur – discontinue treatment. Discolouration Increase dose in severe infections to 500 mg of developing teeth if taken by children or every 6–8 hours mothers during pregnancy. Avoid milk products for 1 hour Oral 20–40mg/kg per day in divided doses every before and 2 hours after taking the drug since 6 hours.

Geneva: World Health Supplemental Zinc on the Growth and Serum Zinc Concentrations of Organization buy discount albuterol 100 mcg line. Lopez order 100 mcg albuterol, and others “Selected Major Risk Factors and Global and Regional Burden of Lee buy albuterol 100mcg with amex, M buy albuterol 100mcg amex. Comparative Quantification of Mortality and Burden of Disease Attributable to Selected Risk Factors | 395 Murray, C. Other Risk Diseases in China and India: The Economic Costs of the Nutrition Factors as the Cause of Smoking-Attributable Mortality: Confounding Transition. Mortality Patterns in National Populations: With Special Reference to Recorded Causes of Death. Interactions of and Pneumonia by Zinc Supplementation in Children in Developing Nutrition and Infection. World Health Organization Monograph Series Countries: Pooled Analysis of Randomized Controlled Trials. Lopez Modern epidemiological studies generally report confidence population preferences for discount rates and uncertainty in or uncertainty intervals around their estimates, often based these estimates, investigators have argued that the choice of on the variation observed in sample data. Estimates of the discount rate for use in analysis is essentially a social value burden of disease and of risk factors, which extrapolate judgment and should not include uncertainty (Morgan and from specific data sources and epidemiological studies to Henrion 1990). Although there is uncertainty about the population-level measures, are subject to a broader range of social value judgment and about its effects on decisions uncertainty because of the combination of multiple data based on the analysis, varying the value deterministically in sources and value choices. Hence, the reported uncertainty the analysis and performing a sensitivity analysis to examine intervals should ideally include all sources of uncertainty, the impact on the outcomes of interest is usually preferable including those arising from measurement error, systematic to uncertainty analysis. In contrast to uncertainty analysis, which the sensitivity of the ranking of causes of the burden of attempts to formally quantify the limitations of available disease globally when discount rates and age weights were data, sensitivity analysis examines how key analytic outputs varied across a range of possible values. Health state valuations, which link mortality information Following Murray and Lopez (1996b), this chapter uses with information on nonfatal health outcomes in summary sensitivity analysis to examine the specific effects of social measures of population health, fit somewhat more ambigu- values that have been incorporated in the design of the ously within the framework of uncertainty analysis. Epidemiologists and demogra- ments about intergenerational equity in choosing a discount phers, who tend to focus on measuring or estimating years of rate, no obvious arguments pertain to the relative impor- life or health without“valuing”either,rarely use discounting. The choice of measurement strategies for argument for discounting is the disease eradication and eliciting health state valuations does sometimes introduce health research paradox. According to this argument, not normative questions, but these pertain to additional consid- discounting future health would lead to the conclusion that erations, such as concern for fair distribution, which are all of society’s health resources should be invested in research orthogonal to the assessment of the health state itself. In addi- tion to individual discounting and discount rates, policies Age Weighting dealing with risk must address the issue of benefits for dif- ferent populations across time. Not all such studies agree that the commensurable with money and cannot be reinvested youngest and oldest ages should be given less weight; nor do elsewhere, but most criticisms of discounting in relation to they agree on the relative magnitude of the differences. Salomon, Majid Ezzati, and others Age weights are perhaps the most controversial value 2. Chapter 6 presents an analysis in which a 0 10 20 30 40 50 60 70 80 90 100 Age (years) more extreme form of age weighting is applied to the deaths of young children. To estimate the total years of life lost due to death at was chosen to give an age pattern similar to that seen in age x, the age-weighting function is integrated over all ages available empirical data. We do not consider vari- weight to younger ages and less to older ages; values of ations in further here. Note that the for the global burden of disease in 2001 to alternative choice of 0. When the discount rate is set to 3 percent, then estimate the net present value of years of life lost. However, changes in the discount rate by broad cause group for low- and middle-income countries. Sensitivity and Uncertainty Analyses for Burden of Disease and Risk Factor Estimates | 403 a. The introduction of nonuni- (percent) or standard or uniform age weighting (K 1 or O, respectively). A zero discount rate gives generally much smaller than the effects of introducing greater importance to causes with a larger burden at younger nonzero discounting. However, the different choices of discount rates and age For both high-income and low- and middle-income coun- weights do not cause any large changes in the rank ordering tries, age weights reduce the importance of the share of the of diseases and injuries, which is to a large degree anchored in burden borne by older people. In low- and middle-income absolute differences in the burden arising from large differ- countries, people aged 60 years and older suffer 21 percent of ences in prevalence and mortality levels across causes. These more detailed 40 Meningitis disease results confirm the major conclusions outlined earlier on the Syphilis impacts of discounting and age weighting. Because eters for the world, for low-and-middle-income countries, childhood and maternal underweight is a risk factor for this 406 | Global Burden of Disease and Risk Factors | Colin D. The burden of disease attributable to risk factors for tive increase in the disease burden attributable to risk factors chronic diseases in adults (high blood pressure, high choles- that affect young children, including childhood underweight; terol, low fruit and vegetable intake, overweight and obesity, indoor smoke from household use of solid fuels; unsafe water, physical inactivity, and smoking) was more sensitive to these sanitation, and hygiene; vitamin A deficiency; and zinc defi- parameters in low- and middle-income countries than in ciency. This is mirrored by a decrease in the disease burden high-income countries because deaths attributable to these attributable to the risk factors for diseases that affect adults, risks occurred at younger ages in the former. By contrast, because the total burden of the chronic diseases affected by the burden of disease attributable to alcohol was much more these risks is reduced. This effect is more noticeable in the sensitive to age-weighting in the high-income countries low- and middle-income countries than in the high-income because many of the hazards of this risk, especially those countries, where childhood mortality is low and the overall related to injuries and neuropsychiatric conditions, occur share of the disease burden is less sensitive to discounting.

Likewise purchase albuterol 100mcg mastercard, following the implementation of Lean principles at Seattle Children’s outpatient center purchase albuterol 100mcg with visa, Bellevue Clinic and Surgery Center generic 100 mcg albuterol visa, there have been multiple process improvements involving operating room access order albuterol 100 mcg with visa. By reviewing work flow and using standard work methods, scheduled operations now begin on time with a 99 percent success rate. Removing wasteful processes for patients with heart attack has dropped the “door-to-balloon” times at Thedacare in Wisconsin from the national average of 90 minutes to 51 minutes. Determining Capacity: Balancing Supply and Demand These examples underscore the untapped capacity that exists in our systems that can be uncovered via a variety of approaches, including applying standard work to provider templates; using the robust data that we have on patient demand by month, day, time, and patient type; redesigning clinic processes to maximize provider availability; and using non-face-to-face visits. At Seattle Children’s, the scheduling and wait time challenges for the ambulatory clinics were found to be both resource and process dependent. Using a variation of level loading—a method used in Lean manufacturing—in our scheduling process, unnecessary variation has been reduced that negatively impacted (supply) or provider availability to meet the needs of patients (demand). However, improving the resource component has been more challenging and has required an in-depth examination of the supply (provider’s availability) and the demand (patient need for visits). An increase in demand for evening appointments was met with the addition of evening clinics and based on trending data for hourly, weekly, and seasonal variation. Like Seattle Children’s, a key component of health care redesign at the Mayo Clinic has been a focus on improving supply through an increased flexibility of provider supply in the 13 ambulatory environment. As part of the vast culture change, full schedules are now set as the expectation for specialty physicians. Rather than allowing schedule gaps, specialists are scheduled to see general patients, adding flexibility to the system through active management of the scheduling system. The complexity of the patients’ lives often results in high no-show rates which can approach 30 percent. Moreover, longer wait times for appointments increase no-show rates, creating a multiplying effect that has a significant impact on access (Parikh et al. A successful strategy employed by Denver Health to maximize appointment utilization included the use of same-day appointments. Another real-time access strategy adopted by Denver Health was a 24/7 nurse advice line, which enabled vulnerable patients with complex lives and transportation challenges to access care when it was convenient for them. This line received over 100,000 calls per year, and patients often were able to use a lower level of care once they spoke to a nurse (Bogdan et al. Kaiser Permanente medical offices evaluated historical data to predict and meet demand. Demand for appointments was known to be greater on Monday mornings with a seasonal fluctuation such as flu season, allergy season, and camp and school physicals. As historical records indicated a 15 to 20 percent no-show rate for mental health visits, Saturday hours were established to reduce missed appointments. Vigilant and dynamic management is required to make on-the-fly adjustments when events happen that upset the balance. Occasionally, heavy lifting is needed by organizational leadership to strike the correct supply balance, especially when it involves standards around the number and length of visits. For subspecialty visits at the Mayo Clinic in Florida, the strategy for appointments requested for primary care physicians or other subspecialists required deviation from the status quo. For patients referred to a specific member of a specialty group the referral model was redesigned to include segmented visits, with only a partial visit or single visit with the sub- subspecialist. This novel use of relatively fixed resources, coupled with process improvements, has ensured that appointments are allocated based on patient preference. Specific subspecialty appointments requested from primary care physicians or other subspecialists required further deviation from the status quo. Redesign of Clinic Work In the Geisinger system, managing work flow in the primary care clinic started with redesign of the office workforce, including the formation of a multidisciplinary team, with new members and new roles, as well as the addition of a case manager. This model is novel in that the physician works in new ways with the adapted teams. The physician remains the leader but shares the responsibilities for patient care with many others. Patients see each team member as an extension of the relationship that they have with their personal physician. As some patient 14 needs could be handled by others on the team, there was a resulting increase in capacity and decrease in wait times. Standard work has included determining assistant roles, standardizing exam rooms to avoid “hunting and gathering” of equipment and supplies, colocating providers with assistants, creating a standard process for placing patients in exam rooms, and standardizing the process of obtaining prescriptions and laboratory visits. In ThedaCare clinics, the application of standard work has resulted in more than 90 percent of ordered laboratory tests performed at the time of the patient visit, with available results within 15 minutes. A key component of the successful model has been the allocation of responsibility of clinic flow to one individual each day, allowing for observation of standard work, intervention when flow stoppers occur, and an understanding of the desired daily performance. Denver Health used Lean to redesign pediatric clinic work flow to eliminate hand-offs and waste between providers and medical office assistants by having them in the exam room at the same time to work in parallel rather than traditional a sequential work flow. This decreased overall visit time while keeping provider patient time the same and allowed for a 12 percent increase in scheduled visits per session (O’Connor et al.