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Background The emergency department is a critical juncture in the trajectory of care of patients with serious, life-limiting illness. Implementation of a clinical decision support (CDS) tool automates identification of older adults who may benefit from palliative care instead of relying upon providers to identify such patients, thus improving quality of care by assisting providers with adhering to guidelines. The Primary Palliative Care for Emergency Medicine (PRIM-ER) study aims to optimize the use of the electronic health record by creating a CDS tool to identify high risk patients most likely to benefit from primary palliative care and provide point-of-care clinical recommendations. Methods A clinical decision support tool entitled Emergency Department Supportive Care Clinical Decision Support (Support-ED) was developed as part of an institutionally-sponsored value based medicine initiative at the Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health. A multidisciplinary approach was used to develop Support-ED including: a scoping review of ED palliative care screening tools; launch of a workgroup to identify patient screening criteria and appropriate referral services; initial design and usability testing via the standard System Usability Scale questionnaire, education of the ED workforce on the Support-ED background, purpose and use, and; creation of a dashboard for monitoring and feedback. Results The scoping review identified the Palliative Care and Rapid Emergency Screening (P-CaRES) survey as a validated instrument in which to adapt and apply for the creation of the CDS tool. The multidisciplinary workshops identified two primary objectives of the CDS: to identify patients with indicators of serious life limiting illness, and to assist with referrals to services such as palliative care or social work. Additionally, the iterative design process yielded three specific patient scenarios that trigger a clinical alert to fire, including: 1) when an advance care planning document was present, 2) when a patient had a previous disposition to hospice, and 3) when historical and/or current clinical data points identify a serious life-limiting illness without an advance care planning document present. Monitoring and feedback indicated a need for several modifications to improve CDS functionality. Conclusions CDS can be an effective tool in the implementation of primary palliative care quality improvement best practices. Health systems should thoughtfully consider tailoring their CDSs in order to adapt to their unique workflows and environments. The findings of this research can assist health systems in effectively integrating a primary palliative care CDS system seamlessly into their processes of care. Trial registration ClinicalTrials.gov Identifier: NCT03424109 . Registered 6 February 2018, Grant Number: AT009844–01.

Chlorine (Cl$\\sb{2}$) and dichlorosilane (SiCl$\\sb{2}$H$\\sb{2}$) play important roles in the manufacture of semiconductor devices. In this dissertation, the chemisorption of Cl$\\sb2$ and SiCl$\\sb2$H$\\sb2$ with Si is studied using soft x-ray photoelectron spectroscopy (SXPS) and photon stimulated desorption (PSD). SXPS studies show that the geometry of the surface plays an important role in the determining the reaction products formed upon the chemisorption of Cl$\\sb2$ on Si(111)-7 x 7 and Si(100)-2 x 1. On the Si(111)-7 x 7 surface, which has a complex reconstruction, both mono- and polychlorides form on the surface. On Si(100)-2 x 1, which has a dimer reconstruction, predominantly silicon monochlorides form. The breaking of Si-Si substrate bonds by Cl atoms that are liberated when Cl$\\sb2$ dissociates is also demonstrated. The reactivity of these liberated Cl atoms is affected by both the type and concentration of the dopant. This leads to a larger chlorosilyl layer on heavily p-doped than on heavily n-doped Si. It is proposed that the larger concentration of holes in the surface region of p-type material facilitates the breaking of a limited number of substrate Si-Si bonds, leading to these differences. PSD is used to elucidate the mechanism for Cl$\\sp{+}$ desorption from Si. These measurements show that Cl$\\sp{+}$ desorption is the result of a transition from the Cl 3s core-level to unoccupied Cl antibonding levels above the valence band maximum, followed by an intratomic Auger decay to form a repulsive state. At the Si 2p edge, Cl$\\sp{+}$ desorption occurs via an indirect process where secondary electrons induce ESD. This is in contrast to the direct desorption which occurs for F$\\sp{+}$ at the Si 2p edge. The differences between F$\\sp{+}$ and Cl$\\sp{+}$ desorption are discussed. The chemisorption of SiH$\\sb{2}$Cl$\\sb{2}$ on Si is studied to investigate and develop methods for growing Si films by atomic layer epitaxy(ALE). SiCl$\\sb{2}$H$\\sb{2}$ chemisorbs dissociatively on Si(111) and Si(100) surfaces resulting in the formation of an SiCl surface species at all temperatures. The coverage of monochloride displays a maximum at temperatures just above the hydrogen desorption temperature. It is observed that molecular hydrogen is not effective in removing an adsorbed layer of Cl from Si. A method for ALE of Si is proposed, in which SiH$\\sb{2}$Cl$\\sb{2}$ is adsorbed onto Si at 600$\\sp\\circ$C and Cl is removed via reaction with atomic H.

Why should you give to the United Way? With one gift, you are helping fund more than 80 different local agencies. More than 30,000 individuals in Osceola County benefit from services provided by United Way agencies. United Way dollars are raised locally and remain in our community. While we are part of a three-county United Way, all the money we raise in Osceola County stays here. United Way is run almost entirely by volunteers. Because of this, 89 cents of every dollar raised goes directly to agencies. Many nationally recognized charities average a 25 percent overhead, as opposed to United Way's 11 percent overhead.