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Changes in the occurrence, character, and longitudinal extent of salinity (S) stratification, and related impacts on dissolved oxygen (DO), in the Seneca and Oswego Rivers, NY, in response to the abatement of ionic pollution of inflowing Onondaga Lake, is documented. The analysis is based on vertical profiles of specific conductance and DO collected over a 20 km reach of the river system for several years before and after the closure of the source of the ionic pollution, a sodaash manufacturing facility. The S difference between the lake and the Seneca River decreased from about 2.6 to 0.7 parts per thousand (%)following the closure; more than 50% of the continuing difference isassociated with lingering ionic waste loading from soda ash production. The occurrence and longitudinal range of the S stratification phenomenon was, and continues to be, highly dependent on river flow. It is most strongly manifested when river flow is low. The occurrence, magnitude, and longtitudinal extent of S stratification have decreased, and vertical exchange between the stratified layers has increased, since the closure, thereby ameliorating the coupled negative impact on the river's oxygen resources. However, under low flow conditions (e.g., probability of occurrence equal to 15%) S stratification continues to extent > 2 km upstream and > 8 km downstream of the point of entry of Onondaga Lake into the Seneca River. Severe DO depletion in the lower river layer, representing violations of New York water quality standards, continues to occur where S stratification prevails. Elimination of the continuing ionic waste inputs from soda ash productionwould further limit the stratification phenomenon and improve the river's DO problem. [ABSTRACT FROM AUTHOR]

Context: Nursing facility residents and their families may identify "comfort measures" as their overall goal of care, yet some hospital transfers still occur., Objectives: Describe nursing facility residents with comfort measures and their hospital transfers., Methods: Mixed methods, including root cause analyses of transfers by registered nurses and interviews with a subset of health care providers and family members involved in transfers. Participants were residents in 19 central Indiana facilities with comfort measures orders who experienced unplanned transfers to the hospital between January 1, 2015 and June 30, 2016. Project demographic and clinical characteristics of the residents were obtained from the Minimum Data Set 3.0. Interviews were conducted with stakeholders involved in transfer decisions. Participants were prompted to reflect on reasons for the transfer and outcomes. Interviews were transcribed and coded using qualitative descriptive methods., Results: Residents with comfort measures orders (n = 177) experienced 204 transfers. Most events were assessed as unavoidable (77%). Communication among staff, or between staff and the resident/family, primary care provider, or hospital was the most frequently noted area needing improvement (59.5%). In interviews, participants (n = 11) highlighted multiple issues, including judgments about whether decisions were "good" or "bad," and factors that were important to decision-making, including communication, nursing facility capabilities, clinical situation, and goals of care., Conclusion: Most transfers of residents with comfort measures orders were considered unavoidable. Nonetheless, we identified several opportunities for improving care processes, including communication and addressing acute changes in status., (Copyright © 2019 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) is a 2-phase Center for Medicare and Medicaid Innovations demonstration project now testing a novel Medicare Part B payment model for nursing facilities and practitioners in 40 Indiana nursing facilities. The new payment codes are intended to promote high-quality care in place for acutely ill long-stay residents. The focus of the initiative is to reduce hospitalizations through the diagnosis and on-site management of 6 common acute clinical conditions (linked to a majority of potentially avoidable hospitalizations of nursing facility residents): pneumonia, urinary tract infection, skin infection, heart failure, chronic obstructive pulmonary disease or asthma, and dehydration. This article describes the OPTIMISTIC Phase 2 model design, nursing facility and practitioner recruitment and training, and early experiences implementing new Medicare payment codes for nursing facilities and practitioners. Lessons learned from the OPTIMISTIC experience may be useful to others engaged in multicomponent quality improvement initiatives., (© 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.)

Objectives: To describe differences in perceived quality of hospice care for individuals living at home or in a nursing home (NH) or assisted living facility (ALF) through analysis of after-death surveys of family members., Design: Retrospective cohort study using hospice medical record data and Family Evaluation of Hospice Care (FEHC) survey data., Setting: Large, national hospice provider., Participants: Individuals who died while receiving routine hospice care and family caregivers who completed after-death quality-of-care surveys., Measurements: Survey results for 7,510 individuals were analyzed using analysis of variance and chi-square tests. Logistic regression was used to assess relationship between location of care and overall service quality., Results: The overall survey response rate was 27%; 34.5% of families of individuals in ALFs in hospice, 27.4% of those at home, and 22.9% of those in NHs returned the survey (P < .001). Differences in return rate according to primary diagnosis were significant, although differences were not large. Most (84.3%) respondents reported that hospice referral had occurred at the right time, and 63.4% rated service quality as excellent. Hospice care in the NH was less likely to be perceived as excellent., Conclusion: There were significant differences in characteristics of individuals whose family members did and did not return surveys, which has implications for use of after-death surveys to evaluate hospice quality. Lower perceived quality of hospice care in NHs may be related to general dissatisfaction with receiving care in this setting. Survey results have the potential to set priorities for quality improvement, choice of provider, and potentially reimbursement. Underlying causes of differences of perceived quality in different settings of care should be examined., (© 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.)

Systematic reductions in the deposition rate of organic C, N, P, and chlorophyll (Chl) are documented for Ca2+ polluted, culturally eutrophic, Onondaga Lake, NY, based on analyses of weekly sediment trap collections over the May-October interval for 10 years of the 1980-1992 period. Inputs of both nutrient-rich domestic waste and industrial salt waste (including Ca2+) decreased over this period. Constituent ratios of the collected sediment indicate phytoplankton biomass was the dominant source of the deposited organic C, N, and Chl. Substantial decreases in downward fluxes of these constituents occurred starting in 1987: 37, 42, 25, and 54%, on average, for organic C, N, P, and Chl, respectively. These reductions were driven primarily by the decreases in the lake's salinity and Ca2+ concentration, that resulted from the closure of a soda ash manufacturing facility (1986), rather than decreases in water column P concentrations from reductions in domestic waste loading. Three different mechanisms for the decreased deposition, related to the reductions in salinity and Ca2+ concentration, are considered: (i) decrease in coating of phytoplankton with CaCO3 precipitate, (ii) increased grazing of phytoplankton by large cladocerans, and (iii) decreases in coagulation of phytoplankton. The greater loss of phytoplankton biomass through deposition, driven by salt waste inputs from the industry, exacerbated the lake's problem of high primary production. This response is consistent with ecological theory for nutrient saturated phytoplankton growth but has not previously been demonstrated on a whole-lake basis.

The recent history of loading of total ammonia (T-NH3) and organic nitrogen (N) from a pharmaceutical manufacturing facility to a municipal treatment plant (Metro) in Syracuse, New York, and the discharge of these constituents from Metro to N-polluted Onondaga Lake is documented. Further, the benefit of the implementation of pretreatment at the pharmaceutical plant, and the effect of an upset event at this treatment facility on loading to Metro and the lake and inlake concentrations are also documented. Models are used as analytical tools to couple loading and in-lake concentrations, to delineate the role that this pharmaceutical facility has played in the lake's ammonia pollution problem, and to evaluate the potential implications of future pretreatment upset events for the success of a rehabilitation program that is underway for the lake. The responsiveness of the lake to reductions in external loading is established by the lower T-NH3 concentration observed in the upper waters of the lake in the spring of 1999. Model analysis demonstrates this reduction was primarily (approximately 75%) because of the decrease in loading from the pharmaceutical facility achieved by pretreatment. An abrupt increase in loading in May 1999 associated with an upset event at the pretreatment facility caused a corresponding increase in the T-NH3 concentration of the lake of approximately 0.5 mg N/L. Model projections demonstrate that the load from the pharmaceutical plant before construction of the pretreatment facility exacerbated the lake's ammonia problems by increasing the occurrence and margin of violations of the toxicity standard. Continued upset events at the pretreatment plant could compromise the lake rehabilitation program.