Improving Guideline-Based Care of Acute Asthma in a Pediatric Emergency DepartmentMatthew P. Gray, MD, MS, a, b, c Grant E. Keeney, MD, MS, d Michael J. Grahl, BS, b Marc H. Gorelick, MD, MSCE, a, b, c Christopher D. Spahr, MDa, b, c
aSection of Emergency Medicine, Department of Pediatrics,
and bMedical College of Wisconsin, Milwaukee, Wisconsin; cChildren’s Research Institute, Children’s Hospital
of Wisconsin, Milwaukee, Wisconsin; and dPediatric
Emergency Medicine, Mary Bridge Children’s Hospital,
Tacoma, Washington
Dr Gray conceptualized and designed the study,
conducted data collection, analyzed the data, and
drafted the initial manuscript; Dr Keeney aided in
conceptualizing and designing the study, aided in
data collection, and revised and reviewed the initial
manuscript; Mr Grahl conducted data collection
and revised and reviewed the initial manuscript;
Dr Gorelick aided in conceptualizing and designing
the study and revised and reviewed the initial
manuscript; Dr Spahr aided in conceptualizing
and designing the study, aided in data analysis,
and revised and reviewed the initial manuscript;
and all authors approved the fi nal manuscript as
submitted.
DOI: 10.1542/peds.2015-3339
Accepted for publication Jul 6, 2016
Address correspondence to Matthew P. Gray, MD,
MS, Department of Pediatrics, Medical College of
Wisconsin, 999 North 92nd St, Milwaukee, WI 53226.
E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,
1098-4275).
Copyright © 2016 by the American Academy of
Pediatrics
FINANCIAL DISCLOSURE: The authors have
indicated they have no fi nancial relationships
relevant to this article to disclose.
FUNDING: No external funding.
It is estimated that 9% of all children
in the United States currently have a
diagnosis of asthma. 1 Asthma is 1 of the
most common reasons children receive
care in an emergency department
(ED), accounting for nearly 2.1 million
visits in the United States in 2009. 2
According to the 2007 National Heart,
Lung, and Blood Institute Expert Panel
Recommendation guidelines (EPR-3), 3
the primary goal of ED care for
asthma exacerbations is the reversal
of airflow obstruction, and rapid
repetitive administration of short-
acting β-agonists (SABAs) has been
shown to be the most effective means
of accomplishing this. 4 – 7
The EPR-3 recommends that patients
with moderate exacerbations receive
abstractBACKGROUND AND OBJECTIVE: Rapid repetitive administration of short-acting
β-agonists (SABA) is the most effective means of reducing acute airflow
obstruction in asthma. Little evidence exists that assesses process measures
(ie, timeliness) and outcomes for asthma. We used quality improvement
(QI) methods to improve emergency department care in accordance with
national guidelines including timely SABA administration and use of asthma
severity scores.
METHODS: The Model for Improvement was used and interventions were
targeted at 4 key drivers: knowledge, engagement, decision support, and
workflow enhancement. Time series analysis was performed and outcomes
assessed on statistical process control charts.
RESULTS: Asthma severity scoring increased from 0% to >95% in triage and to
>75% for repeat scores. Time to first SABA (T1) improved by 32.8 minutes
(47%). T1 for low severity patients improved by 17.6 minutes (28%). T1
for high severity patients improved by 3.1 minutes to 18.1 minutes (15%).
Time to third SABA (T3) improved by 30 minutes (24%). T3 for low severity
patients improved by 42.5 minutes (29%) and T3 for high severity patients
improved by 21 minutes (23%). Emergency department length of stay
for low severity patients discharged to home improved by 29.3 minutes
(15%). The number of asthma-related visits between 48-hour return
hospitalizations increased from 114 to 261. The admission rate decreased
6.0%.
CONCLUSIONS: We implemented standardized asthma severity scoring with
high rates of compliance, improved timely administration of β-agonist
treatments, demonstrated early improvements in Emergency department
length of stay, and reduced admission rates without increasing unplanned
return admissions.
QUALITY REPORTPEDIATRICS Volume 138 , number 5 , November 2016 :e 20153339
To cite: Gray MP, Keeney GE, Grahl MJ, et al. Impro-
ving Guideline-Based Care of Acute Asthma in a
Pediatric Emergency Department. Pediatrics. 2016;
138(5):e20153339
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GRAY et al
up to 3 doses of SABA within their
first hour of care and those with
severe exacerbations should receive
1 dose of SABA every 20 minutes
or the continuous administration
of SABA for the first hour of care.
A 2003 Cochrane Systematic
Review of randomized control
trials demonstrated decreased
admission rates for patients receiving
continuous versus intermittent
administration of SABA, suggesting
that more timely receipt of higher
doses of SABA may improve
outcomes. 4
Despite these findings and the EPR-3
recommendations, we identified
only 1 study directly assessing
the relationship between timely
administration of SABA and outcome
measures such as ED length of stay
(EDLOS) and admission rate. 8 Sills et al 8
found no significant relationship
between timely SABA administration
and EDLOS or admission rate;
however, timeliness was based on
the administration of at least 1 SABA
within 60 minutes of ED arrival. Our
aim is to improve the percentage of
patients who receive up to 3 SABA
treatments within 1 hour of triage,
which may have more significant
impact on outcomes.
In addition to timely and effective
administration of SABA, effective ED
management includes the assessment
of initial severity of illness and the
subsequent response to treatment.
There is no single best measure
of severity; however, sign and
symptom scores are useful aids and
can be predictive of hospitalization
especially when repeat scores are
obtained after treatment. 9 – 14
Current-state assessment
demonstrated appropriate use of
corticosteroids and ipratropium;
however, it revealed opportunity to
improve both time to SABA therapy
and adherence to standardized
clinical assessments. Baseline
time to first SABA (T1) was 71.8
minutes and baseline time to third
SABA (T3) was 125.6 minutes. We
theorized that (1) ED provider
awareness of the safety and benefit
of early and rapid administration of
SABAs, (2) a standardized process
of assessing illness severity, and (3)
electronic medical record (EMR)
tools to support a new care process
would lead to a decrease in time
to SABA administration, EDLOS,
and admission rates for patients
presenting with asthma.
Our primary aims for this project
were to (1) record a Pediatric Asthma
Severity Score 10, 11 (PASS) in triage for
90% of patients presenting with an
asthma exacerbation; (2) to record at
least 1 repeat PASS within 2 hours of
triage for 75% of patients presenting
with an asthma exacerbation; and (3)
reduce time to first and third SABA
by 25%. Our goal was to accomplish
these aims within 12 months.
Our secondary aims were to (1)
decrease EDLOS for both admitted
and discharged asthma patients; and
(2) decrease admission rate. Asthma-
related return visits within 48 hours
resulting in admission and EDLOS for
all patients were tracked as balancing
measures.
e2
FIGURE 1Key driver diagram for implementation of PASS and improvement of timely SABA administration.
TABLE 1 Tools Implemented in EMR to Support Asthma Clinical Pathway
Tool Purpose
PASS in EMR Improve scoring compliance. Available on all computers (bedside) and auto-
calculates net score
Provider asthma
order set
Facilitate order entry and standardize treatment
Asthma respiratory
report
Facilitate rapid assessment of PASS and vital sign trends in relation to medication
administration
Triage protocol Improve timely administration of fi rst SABA. Standing protocol order allowing for
nurse-initiated administration of initial SABA
Nurse order set Facilitate nurse order entry and improve compliance with triage protocol use
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PEDIATRICS Volume 138 , number 5 , November 2016
METHODS
Setting and Context
The Children’s Hospital of
Wisconsin’s ED is a tertiary pediatric
ED with 36 ED beds that sees over
60 000 visits annually. Asthma is the
most common admitting diagnosis
from the ED. Our ED is staffed by at
least 1 pediatric emergency medicine
(PEM) attending or fellow at all
times. Fellows, advanced practice
providers, and resident physicians
assess patients and write orders
for medications/interventions. ED
nurses administer intermittent
and continuous β-agonist therapy
for nearly all asthma patients.
Respiratory therapists aid in the
care of only the most severely ill
patients. This improvement work
was supported by the section chief of
PEM and ED nursing leadership.
Our improvement work coincided
with implementation of a full EMR
at our institution. Transition to a
comprehensive EMR occurred in
November 2012. Before full EMR
implementation, computerized
order entry was in use; however, no
standing asthma order sets existed.
Interventions
The Model for Improvement 15
was used as a framework for our
improvement project. A project
team of PEM physicians, nurses, and
administrative leaders including
the section chief of PEM and clinical
nurse supervisor was established.
Process mapping (Supplemental
Figs 12, 13, and 14) and key driver
diagrams ( Fig 1) were used to
gain better understanding of our
system of care and to prioritize
interventions.
Process maps demonstrated significant
interprovider variation and highlighted
areas for improvement. These
included reducing wasted time in the
process of order entry and medication
administration. Appropriate variations
in the timeliness of care on the basis
of presenting severity were identified
suggesting interventions needed to
account for this difference and needed
to be designed to address specific
populations on the basis of severity of
illness.
Our improvement efforts included
all patients 2 to 18 years of age seen
in the ED from May 2012 through
November 2015 that received at
least 1 SABA in the ED. Patients were
excluded based on comorbidities
including sickle cell disease, chronic
lung disease, congenital heart
disease, and concurrent pneumonia.
Patients were identified based
on International Classification of Diseases, Ninth Revision codes (493.
xx) assigned to the visit.
Interventions were carried out in 2
phases. Phase 1 started July 2012
e3
FIGURE 2P-chart demonstrating compliance with PASS scoring in triage.
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and focused on standardized PASS
assessments and provider education
of best practices. Phase 2 commenced
once standardized assessments were
being done with high reliability and
focused on the development and
implementation of a clinical care
pathway and enhancement of clinical
workflow through integration of
tools developed within the EMR.
During phase 1 we implemented
the PASS as our standardized
asthma severity assessment tool.
The PASS has good interrater
reliability and is predictive of the
need for ongoing care. 10, 11 PASS
scores were integrated into the
clinical pathway (Supplemental
Fig 15) and care initiation triage
protocol implemented in phase 2.
The tool was initially introduced on
paper and was quickly transitioned
to electronic scoring with EMR
implementation in November
2012. Implementation included
lecture-based and just-in-time
education of physicians and
nurses on use of the tool.
Simultaneously, best practice
seminars were held for all providers
emphasizing recommendations
from the EPR-3 3 including use
of standardized asthma severity
assessments, timely and repetitive
SABA administration, adjunctive
use of ipratropium, and early
corticosteroid administration.
Phase 2 focused on implementation of
a clinical care pathway for all patients
presenting with asthma. ED-based
clinical pathways have been shown
to reduce EDLOS and admission rates
for asthma, as well as other acute
illnesses. 16, 17 In keeping with EPR-3 3
recommendations, our pathway was
stratified by presenting severity of
illness (Mild = PASS 0–1, Moderate =
PASS 2–3, Severe = PASS 4–6) to limit
unnecessary exposure to medication
while still providing optimal care.
After development of our clinical care
pathway, decision support tools were
developed to translate the pathway
into clinical practice ( Table 1).
To further improve T3, a second
best-practices seminar focused on
provider care patterns was held in
November 2014. Analysis of interval
data demonstrated that >75% of
patients with severe exacerbations
(PASS ≥4) received a minimum of
3 SABA treatments; however, these
treatments were rarely received
within the first hour of care. As
part of the best practices seminar,
we recommended that continuous
albuterol should be strongly
considered as initial treatment
of patients with severe
exacerbations.
Finally, we implemented an
audit and feedback process for
provider-specific performance
for T3 and nursing compliance
e4
FIGURE 3P-chart demonstrating compliance with repeat PASS scoring.
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PEDIATRICS Volume 138 , number 5 , November 2016
with triage protocol use. Data
were shared on a quarterly basis.
Provider performance was shared
in a deidentified manner allowing
comparison with peer performance.
Study of the Interventions
Time series analysis was used
to assess impact of individual
interventions. Process and outcome
measures were assessed monthly.
Stratification was used to assess
variation on the basis of differences
in presenting asthma severity.
Rational subgrouping was used to
analyze variation between individual
providers to direct an audit and
feedback process. Statistical
process control (SPC) charts for T3,
subgrouped by individual provider,
were generated (Supplemental Fig
16). Total SABA administrations
before and after our interventions
were measured to assess possible
unintended outcomes.
Measures
Triage start time was identified as
time zero for time-related metrics as
we felt that triage start time reflects
the beginning of the active phase of
care, and significant change to the ED
triage process was not in scope. We
defined 3 SABA treatments as either
3 individual treatments (given every
20 minutes) or 1 hour of continuous
SABA treatment (dose-equivalent to
3 individual treatments). If a patient
received continuous SABA as their
initial treatment, T3 was defined as
administration time plus 40 minutes.
Similarly, if a continuous SABA was
given as the second treatment, T3
was defined as administration time
plus 20 minutes. Analysis of baseline
data demonstrated differences in
outcomes on the basis of initial PASS
score. Several stratification models
were tested and a binary model with
a threshold PASS of >3 demonstrated
the greatest difference between
groups and reduction of within-
group variation. Therefore, in our
measurement plan and reporting,
results are stratified by initial PASS
score of ≤3 and >3.
Analysis
SPC charts were used to assess change
over time and rules for special cause
variation were followed and used to
adjust the mean. 18 PASS compliance
and admission rate were analyzed
with p-charts. Time to treatment
and EDLOS were analyzed with
x-bar charts. Return visits resulting
in admission were infrequent and
therefore analyzed with a g-chart.
SPC charts were generated by
using QI-Charts (Version 2.0.22,
Copyright 2009, Scoville Associates).
Differences in median EDLOS and
total albuterol administration pre-
and postintervention were measured
using the Mann-Whitney test. This
analysis was conducted with SAS
e5
FIGURE 4X-bar chart demonstrating improved T1 for all patients.
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Enterprise Guide 6.1 (SAS Institute,
Cary, NC).
Ethics
The Children’s Hospital of Wisconsin
Institutional Review Board
reviewed our project and deemed
it quality improvement (QI) work
not constituting human subjects
research. To protect privacy, data
were abstracted to and stored in a
secure database.
RESULTS
From May 2012 through November
2015, there were 5552 patient
encounters meeting inclusion
criteria. The PASS score was
successfully implemented and
scores have been obtained in triage
>95% of the time ( Fig 2) for over 3
years. Repeat PASS scores have been
documented within 2 hours 76% of
the time for over 2 years ( Fig 3).
Results are reported for the entire
population and stratified by severity
(low severity = PASS ≤3, high
severity = PASS >3). T1 improved
from 70.0 minutes to 37.2 minutes
(32.8 minutes, 47% reduction; Fig
4). Some gain was temporarily lost
between September 2014 and May
2015 during which time the mean T1
was 41.9 minutes; however, special
cause variation was again noted
starting June 2015 and T1 has been
maintained at 37.2 minutes for 6
months
We hypothesized that increased
census and decreased nurse/
provider to patient ratio negatively
impacted T1 from September to May
2015. Monthly census was charted on
a c-chart and special cause variation
was noted from September 2014
through May 2015 (Supplemental Fig
17). Average monthly census during
this period was increased by nearly
900 visits. Some of this variation is
likely due to the enterovirus D68
outbreak identified across North
America during the fall of 2014 as
it was associated with increased
severe respiratory illnesses among
children. 19, 20
T1 for the lower severity patients
improved from 62.7 minutes to
45.1 minutes (17.6 minutes, 28%
reduction; Fig 5). Baseline T1 for high
severity patients approached the goal
time at 21.2 minutes and improved
to 18.1 minutes (3.1 minutes, 15%
reduction) and has been sustained
for 11 months ( Fig 6).
T3 for the entire population
improved from 122.6 minutes to
92.6 minutes (30.0 minutes, 24%
decrease) and has been sustained
for 20 months ( Fig 7). T3 for low
severity patients improved from
148.5 minutes to 106.0 minutes
(42.5 minutes, 29% reduction) and
has been sustained for 20 months
FIGURE 5X-bar chart demonstrating improved T1 for patients with initial PASS from 0 to 3.
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PEDIATRICS Volume 138 , number 5 , November 2016 e7
( Fig 8). T3 for high severity patients
improved from 92.2 minutes to
71.0 minutes (21.2 minutes, 23%
reduction; Fig 9) and has been
sustained for 8 months.
Initial goals for PASS compliance
as well as our initial goal of a
25% reduction in T1 were met.
Additionally, we nearly met our 25%
reduction goal for T3 in the entire
population (24% reduction), and
did see meaningful improvement
in T3 for both low severity (29%
reduction) and high severity
patients (23% reduction). For
patients with severe exacerbations,
T1 currently meets guideline
recommendations while T3 now
more closely approaches guideline
recommendations.
In addition to severity, EDLOS
analysis was stratified by disposition
(admission/discharge). EDLOS
for admitted low severity patients
remained stable at 323 minutes
during the study period, whereas
EDLOS for admitted high severity
patients remained stable at 304
minutes. EDLOS for discharged low
severity patients improved from
191.7 minutes to 162.4 minutes
(29.3 minutes, 15% reduction) and
this reduction has been sustained
for 13 months ( Fig 10). EDLOS for
discharged high severity patients
remained stable at 188 minutes.
To further assess the impact of
timely treatment, we examined if
receipt of 3 SABA within 60 minutes
(guideline recommendations)
affected EDLOS. Admitted patients
who met guideline recommendations
had a significantly shorter EDLOS;
289 minutes compared with 332
minutes (P < .001). EDLOS for
discharged patients meeting this
guideline recommendation was also
shorter; 210 minutes compared with
225 minutes but was not significant
(P = .067).
Differences in total SABA
administration were measured
before and after the recommendation
to initiate care with continuous
albuterol for patients with severe
exacerbations. Before the update,
discharged patients with severe
exacerbations received an average
of 2.9 treatments compared with
3.6 treatments after the update
(P < .001), and admitted patients
received an average of 5.7 treatments
compared with 6.4 treatments after
the update (P < .001). This was a net
increase of <1 treatment per patient
in both groups.
In December 2014 special cause
variation was noted for admission
rate ( Fig 11), which dropped from
26.4% to 20.4% (6.0% absolute
change, 23% relative change) and
FIGURE 6X-bar chart demonstrating improved T1 for patients with initial PASS from 4 to 6.
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FIGURE 7X-bar chart demonstrating improved T3 for all patients.
FIGURE 8X-bar chart demonstrating improved T3 for patients with initial PASS from 0 to 3.
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FIGURE 9X-bar chart demonstrating improved T3 for patients with initial PASS from 4 to 6.
FIGURE 10X-bar chart demonstrating decreased EDLOS for discharged patients with initial PASS 0 to 3.
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has been sustained for 12 months.
During this period, we also noted
improvement and special cause
variation in T1 and T3 for patients
with severe exacerbations ( Figs 6
and 9).
Between July 2012 and November
2015, there were 21 return visits
within 48 hours resulting in
admission; 0.39% of all patients
presenting with asthma. Special
cause was noted in January 2014
(Supplemental Fig 17). Before this,
there was an average of 114 asthma-
related patient visits between return
admissions compared with 261 from
January 24th through November
30th, 2015. Additionally, we saw
no significant effect on EDLOS for
the entire ED population during the
intervention phases. Median EDLOS
for admitted patients remained stable
at 269 minutes, whereas median
EDLOS for discharged patients
remained stable at 125 minutes.
DISCUSSION
Through application of QI
methodology and the integration of
evidence into clinical workflow, we
standardized asthma assessments
with high rates of compliance and
improved timely administration of
SABA for patients seen with acute
asthma exacerbations. Our findings
suggest that timely and efficient
care may lead to reductions in both
EDLOS and admission rates. This is
evidenced by the gains demonstrated
in EDLOS for low severity patients
discharged to home, and the fact
that admitted patients who received
their first 3 SABA within 60 minutes
had significantly reduced EDLOS.
Additionally, improvement in T3 for
patients with severe exacerbations
coincided with improvement in
admission rates.
Although we did see a statistically
significant increase in total SABA
administration, it is unclear if this
change was clinically significant
or a negative effect. Improvement
in T3 and increased albuterol
administration coincided with
decreased admission rates. Although
the temporal relationship suggests
that early aggressive treatment
may positively affect admission
rate, further study is needed to fully
elucidate this relationship.
Several factors enabled our efforts.
Implementation of a nurse triage
protocol generated nurse buy-in and
removed significant waste in early
care. Although EMR implementation
has been shown to have transient
negative effects on patient flow in
an ED setting, 21 – 24 implementation
facilitated development of higher
reliability interventions. This
is clearly seen by the dramatic
improvement in PASS documentation
compliance coinciding with EMR
implementation. Lastly, stratifying
e10
FIGURE 11P-chart demonstrating decreased admission rate.
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PEDIATRICS Volume 138 , number 5 , November 2016
our results by presenting severity
allowed us to identify distinct
populations and target our
interventions.
Although we demonstrated
improvement of EDLOS for
discharged patients with low
severity exacerbations, we did not
demonstrate other improvements
in LOS. Timely receipt of therapy is
likely not the primary determinant
of EDLOS. For admitted patients
especially, there are multiple
downstream constraints outside
the scope of this specific initiative.
Additionally, the need to quickly
identify patients requiring ongoing
treatment in the hospital must be
balanced with accurate identification
of the correct population to avoid
unnecessary hospitalizations and
cost. Further gains are most likely to
be had with continued efforts focused
on patients with mild exacerbations.
This will require the careful
allocation of resources to ensure that
we do not negatively impact the care
of other sicker patients who arguably
need the timeliest care.
During the intervention period,
providers received feedback on
multiple metrics related to asthma
care increasing awareness that may
have produced a Hawthorne effect
in part responsible for the reduction
in 48-hour return admissions.
Increased awareness of performance
may have changed behaviors
regarding discharge decisions.
Similar improvements have also
been seen with implementation
of ED clinical pathways for acute
illnesses. 12
Our study has several limitations.
This study was conducted at a
single institution, which may limit
generalizability of our findings or
the ability for other institutions to
implement similar interventions. At
the time of this initiative, we did not
have the resources to conduct a cost
analysis. Continued measurement
is needed to ensure sustained
improvement. Despite these
limitations, our findings suggest that
integration of evidence into clinical
workflow can drive improvement.
CONCLUSIONS
We successfully improved timeliness
of care for patients with acute asthma
exacerbations without
negatively affecting 48-hour
return admissions or EDLOS
for all patients. To our knowledge,
this is the first study reporting
results for the timely and
repetitive administration of
multiple SABAs within an
hour and the effect on EDLOS
and admission rates at a large
academic pediatric ED.
e11
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential confl icts of interest to disclose.
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ABBREVIATIONS
ED: emergency department
EDLOS: ED length of stay
EMR: electronic medical record
EPR-3: National Heart, Lung, and
Blood Institute Expert
Panel Recommendation
guidelines
PASS: Pediatric Asthma Severity
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medicine
QI: quality improvement
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SPC: statistical process control
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DOI: 10.1542/peds.2015-3339 originally published online October 26, 2016; 2016;138;Pediatrics
Christopher D. SpahrMatthew P. Gray, Grant E. Keeney, Michael J. Grahl, Marc H. Gorelick and
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DOI: 10.1542/peds.2015-3339 originally published online October 26, 2016; 2016;138;Pediatrics
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