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Background:Patients presenting to the Emergency Department (ED) may be subjected to unnecessary bloodwork. This leads to excessive work for front-line nurses, physicians and laboratory staff, contributing to increased ED length of stay (LOS), patient discomfort, and health care costs. Aim Statement:By January 1, 2020, we will reduce the number of targeted blood tests (AST, GGT, aPTT and CK) by 40% in the Mount Sinai ED, as measured by the percent per 1000 ED visits of AST to ALT, GGT to ALT, aPTT to INR and CK to troponin. Measures & Design:This was a prospective time series quality improvement study. Using the Model for Improvement, we engaged front-line ED staff, as well as stakeholders from Consultant, Laboratory and Information Services. Data was analyzed using run chart rules. Intervention: a) Removed rarely used tests from electronic nursing order sets b) Uncoupled order panels c) Developed six presentation-based medical directives with appropriate blood testing. d) Staff education Family of measures Outcomes: percent of targeted uncoupled test per 1000 ED visits for each of AST to ALT, GGT to ALT, aPTT to INR, and CK to troponin; Total number of blood tests ordered per 1000 ED visits Process: number of “separate and hold” tubes; number of blood tubes used in the ED; proportion of staff attending education Balancing: volume of blood drawn; LOS Evaluation/Results:Outcome: Estimated relative reduction in proportion of all uncoupled tests per 1000 ED visits by: • 33% AST/ALT • 52% GGT/ALT • 50% CK/troponin •18% aPTT/INR Total number of lab tests per 1000 ED visits decreased by 7.7% (5742 to 5331). Evidence of special cause variation on all outcomes. Process measures: 1. 100% reduction in weekly “Separate and Hold” tubes (56 to 0). 2. Monthly total of blood tubes used in the ED decreased by 2.8% (11620 to 11300) 3. Attendance pending. Balancing measures: Monthly average volume of blood drawn decreased by 1.4L(2%) from 50.4L to 49.0L; LOS pending Discussion/Impact:A multi-pronged intervention resulted in a decrease in blood testing in the ED. We achieved the sub-aim of reducing targeted blood tests and are on track to achieve the overall aim of total lab reduction in the ED by April 2020. Final interventions to be implemented in the coming months include changes to the ED paper record and replacement of the paper add-on order process with an electronic ordering tool. Complete data will be available by April 2020. This intervention is scalable and has the potential to reduce costs and preventable harm to patients.

A planar waveguide Nd:YAG laser is pumped with 430 W of power from 10 laser diode bars to produce a multimode output power of 150 W at an optical efficiency of 35%. Use of a hybrid resonator of the positive-branch confocal unstable type for the lateral axis and of one of the near–case I waveguide type for the transverse axis increased the laser brightness by a factor of ∼26 with only 12% less power than in the multimode case.

We have observed giant pulses from cw pumped, monolithic Nd:YVO_4 microchip lasers, several hundred times the cw level, with pulse lengths less than 2??ns, which cannot be accounted for by conventional gain switching. These pulses occur as the second longitudinal mode starts to oscillate and can be described by the inclusion of gain-related effects in the formation of a stable cavity.

We have observed giant pulses from cw pumped, monolithic Nd:YVO_4 microchip lasers, several hundred times the cw level, with pulse lengths less than 2 ns, which cannot be accounted for by conventional gain switching. These pulses occur as the second longitudinal mode starts to oscillate and can be described by the inclusion of gain-related effects in the formation of a stable cavity.

We report a singly resonant pulsed intracavity KTiOPO_4 optical parametric oscillator that uses a semimonolithic microchip laser design. The compact (50-mm-long), low-threshold (1.3-W) cavity uses a novel quadrupole deflector Q switch to give 4?µJ pulses at 1.064 µm and 0.4?µJ signal pulses of 5.6-ns duration at 1.53 µm with a repetition frequency of 5??kHz when it is pumped with a 2-W laser diode. The signal pulses are diffraction limited and single frequency.