In this article, the heat, momentum and mass (species) transfer in external boundary layer flow of Casson nanofluid from an isothermal sphere surface is studied theoretically. The effects of Brownian motion and thermophoresis are incorporated in the model in the presence of both heat and nanoparticle mass transfer. The governing partial differential equations (PDEs) are transformed into highly nonlinear, coupled, multi-degree non-similar partial differential equations consisting of the momentum, energy and concentration equations via appropriate non-similarity transformations. These transformed conservation equations are solved subject to appropriate boundary conditions with a second order accurate finite difference method of the implicit type. The influences of the emerging parameters i.e. Casson fluid parameter (β), Buoyancy ratio parameter (N), Brownian motion parameter (Nb) and thermophoresis parameter (Nt), Lewis number (Le) and Prandtl number (Pr) on velocity, temperature and nano-particle concentration distributions are illustrated graphically and interpreted at length. Validation of solutions with a Nakamura tridiagonal method has been included.

In 1996, the St. John's region had a population of 8,435 > or = 75 years, with 996 nursing home (NH) beds and 550 supervised care (SC) beds. A single entry system to these institutions was implemented in 1995. To determine the impact of the single entry system, the demographic and clinical characteristics of NH residents were assessed in 1997 (N = 1,044) and in 2003 (N = 963). To determine the efficiency of placement and the need for long-term care beds, two incident cohorts requesting placement were studied in 1995/96 (N = 467) and in 1999/2000 (N = 464). Degree of disability was determined using the Residents Utilization Groups III classification (RUG-III) and the Alberta Resident Classification Score (ARCS), and time to placement and to death was measured. In prevalent NH residents, the percentage without RUGS-III disability decreased from 18.5% in 1997 and to 9.9% in 2003. The proportion recommended for NH was 75% in 1995/96 and 72% in 1999/2000, despite the fact that the proportion with RUGS-III disability was 64% in both periods. Using a decision tree, optimal placement for the 1999/2000 cohort was 36% to SC, 20% to SC for the cognitively impaired, and 44% to NH. Predicted need for long-term care beds in 2004 matched poorly with current provision of NH and SC beds, and the mismatch will be worse in 2014. It was concluded that the single entry system was associated with improved appropriateness of NH bed utilization. However, there was a mismatch in need for and provision of institutional long-term care. Investment in the reconfiguration of long-term care beds by case mix and by geography is necessary.

En 1996 la région de St. John's comptait une population de 8 435 personnes âgées de plus de 75 ans, 996 lits dans des foyers de soins infirmiers (FSI) et 550 lits de soins sous surveillance (SSS). Un système d'admission à point unique à ces établissements a été mis en œuvre en 1995. Afin de déterminer l'incidence du système d'admission à point unique, les caractéristiques démographiques et cliniques des résidents de FSI ont été évaluées en 1997 (N = 1 044) et en 2003 (N = 963). Afin de déterminer l'efficacité du placement et le besoin de lits de soins de longue durée, deux cohortes d'incidents nécessitant un placement ont été étudiées en 1995–1996 (N = 467) et en 1999–2000 (N = 464). Le niveau de déficience a été déterminé à l'aide de la classification des Resource Utilization Groups III (RUG-III) et l'Alberta Resident Classification Score (ARCS), puis le temps écoulé entre le placement et le décès a été mesuré. Chez les résidents courants des FSI le pourcentage de clients ne souffrant d'aucune déficience aux termes de la classification RUGS-III a diminué de 18,5 % en 1997 et de 9,9 % en 2003. La proportion recommandée de ces clients dans les FSI était de 75 % en 1995–1996 et de 72 % en 1999–2000, malgré le fait que la proportion de résidents atteints d'une déficience aux termes de la classification RUGS-III était de 64 % au cours des deux périodes. À l'aide d'un arbre de décision, un placement optimal pour la cohorte de 1999–2000 a été établi à 36 % dans les établissements de SSS, à 20 % pour les résidents de SSS souffrant de facultés cognitives altérées et à 44 % dans les FSI. Le besoin prévu de lits de soins de longue durée en 2004 ne correspondait que faiblement à l'inventaire actuel de lits de FSI et de SSS et ce manque à gagner sera bien pire en 2014. Nous avons conclu que le système d'admission à point unique était associé à une utilisation améliorée des lits en FSI de façon appropriée. Cependant, il y avait un manque à combler dans le besoin de lits de soins de longue durée en établissement et l'inventaire de ces lits. Un investissement dans la reconfiguration des lits de soins de longue durée par composition de la clientèle et par géographie est nécessaire.

Local Mentors: Carrie Wieneke, MD, and Michael Moxley, MD APGO Advisors: Alice R. Goepfert, MD, and Lee A. Learman, MD, PhD PURPOSE: To develop an educational module introducing high value care concepts to obstetrics and gynecology residents. BACKGROUND: Cost effective care is one of the 28 ACGME milestones to be achieved during residency training. It is imperative that physicians are aware of the components of the cost of medical care and how to maintain quality while containing cost. METHODS: Needs assessment was performed by surveying graduating seniors and junior faculty. Knowledge gaps were identified and an introductory educational module was designed. This module provides basic information defining high value care and how it can be achieved in clinical settings using a few simple tools; it was presented as an interactive small group discussion with activities illustrating cost-effective care using real life examples. EVALUATION PLAN: Participants of the study were OB/GYN residents (n=26) at two academic institutions. The introductory module started with a pretest. Evaluation of knowledge gained and decay was performed by an immediate post-test and a retention test 3 months later. The testing results are reported elsewhere. DISSEMINATION: In addition to submission to CREOG-APGO Annual Meeting, the module can be disseminated through AAMC MedEdPORTAL. REFLECTIVE CRITIQUE: Traditionally, the attitude of American medical care has been to use all available resources. A shift to taking care of patents using only the appropriate resources is a culture shift for both learners and teachers. Creating a module that is informative and interesting while achieving the goal of changing practice styles was challenging. Development of a robust national curriculum for ob/gyns should be undertaken.

INTRODUCTION: Tetanus, Diphtheria and acellular Pertussis (Tdap) vaccination is recommended by the CDC between 27 and 36 weeks gestation in order to maximize maternal antibody response and passive antibody transfer to the infant. This study was developed as a quality improvement project for increasing vaccination rates in our university-based clinic. METHODS: We developed a best practice advisory alert in the electronic medical record that was implemented September 8, 2016. This alert prompts providers to order the Tdap vaccine or document previous vaccination. It is triggered during clinic visits between 27 and 36 weeks gestation. A chart review was completed for all deliveries at our hospital during a 3 month period prior to implementation and 3 month period post-implementation. A χ2 test was completed to assess differences in Tdap uptake pre- and post-implementation. A Breslow-Day test was completed to identify any differences in uptake by age, parity, and time after initiation. RESULTS: A total of 531 pre-implementation and 574 post-implementation charts were reviewed and included in the analysis. The rates of appropriately timed Tdap vaccinations was significantly higher post-implementation than pre-implementation (60.28% versus 39.72% P<.0001). This change was most noticeable in the first month after implementation (P=.0123). CONCLUSION: Use of a pop-up reminder in the electronic medical record increased Tdap vaccination rates among women during their third trimester. Although with maximum vaccination rates less than 70% at the peak, more can be done to educate providers and patients about the importance of antepartum vaccination.

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Local Mentors: Michael Moxley, MD, and Carrie Wieneke, MD APGO Advisors: Lee A. Learman, MD, PhD, and Alice R. Goepfert, MD PURPOSE: To evaluate the short and long-term retention of knowledge of cost effective care gained by residents after a pilot intervention. BACKGROUND: Increasingly, physicians are expected to practice cost conscious medicine. Resident education must include a basic understanding of cost for their future practice patterns and to fulfill an ACGME milestone. METHODS: A high value care module was developed and implemented at 2 academic Obstetrics and Gynecology residency programs comprising 32 residents. Module development is described in a separate report. A survey assessing knowledge was developed, pre-tested, refined and conducted before and after the intervention to determine immediate knowledge change and then at 3 months post intervention to determine knowledge decay. RESULTS: Of the 26 residents participating in the intervention, 62% reported no prior education regarding cost-effective care and as the remainder reported their prior education as “on the fly with an Attending.” The percent reporting somewhat to very little knowledge of cost effective care principles fell from 85% to 65% immediately after the intervention (t=1.61; P=.06) and to 63% after 3 months. Residents' tested knowledge improved from 31% correct to 69% immediately post intervention (t=2.95; P=.002) and decayed to 46% at 3 months (t=1.13; .13). DISCUSSION: A module addressing the cost-effective care milestone for Obstetrics and Gynecology residents improved low baseline knowledge with moderate decay after 3 months. Next steps will include a larger study of multidisciplinary residents with ongoing study of methods to reinforce knowledge long-term.