Emergency Health Services (EHS) : demand and service delivery models. monograph 3 : patients’ reasons and perceptions

Executive Summary Emergency health is a critical component of Australia’s health system and emergency departments (EDs) are increasingly congested from growing demand and blocked access to inpatient beds. The Emergency Health Services Queensland (EHSQ) study aims to identify the factors driving increased demand for emergency health and to evaluate strategies which may safely reduce the future demand growth. This monograph addresses the perspectives of users of both ambulance services and EDs. The research reported here aimed to identify the perspectives of users of emergency health services, both ambulance services and public hospital Emergency Departments and to identify the factors that they took into consideration when exercising their choice of location for acute health care. A cross-sectional survey design was used involving a survey of patients or their carers presenting to the EDs of a stratified sample of eight hospitals. A specific purpose questionnaire was developed based on a novel theoretical model which had been derived from analysis of the literature (Monograph 1). Two survey versions were developed: one for adult patients (self-complete); and one for children (to be completed by parents/guardians). The questionnaires measured perceptions of social support, health status, illness severity, self-efficacy; beliefs and attitudes towards ED and ambulance services; reasons for using these services, and actions taken prior to the service request. The survey was conducted at a stratified sample of eight hospitals representing major cities (four), inner regional (two) and outer regional and remote (two). Due to practical limitations, data were collected for ambulance and ED users within hospital EDs, while patients were waiting for or under treatment. A sample size quota was determined for each ED based on their 2009/10 presentation volumes. The data collection was conducted by four members of the research team and a group of eight interviewers between March and May 2011 (corresponding to autumn season). Of the total of 1608 patients in all eight emergency departments the interviewers were able to approach 1361 (85%) patients and seek their consent to participate in the study. In total, 911 valid surveys were available for analysis (response rate= 67%). These studies demonstrate that patients elected to attend hospital EDs in a considered fashion after weighing up alternatives and there is no evidence of deliberate or ill-informed misuse. • Patients attending ED have high levels of social support and self-efficacy that speak to the considered and purposeful nature of the exercise of choice. • About one third of patients have new conditions while two thirds have chronic illnesses • More than half the attendees (53.1%) had consulted a healthcare professional prior to making the decision. • The decision to seek urgent care at an ED was mostly constructed around the patient’s perception of the urgency and severity of their illness, reinforced by a strong perception that the hospital ED was the correct location for them (better specialised staff, better care for my condition, other options not as suitable). • 33% of the respondent held private hospital insurance but nevertheless attended a public hospital ED. Similarly patients exercised considered and rational judgements in their choice to seek help from the ambulance service. • The decision to call for ambulance assistance was based on a strong perception about the severity of the illness (too severe to use other means of transport) and that other options were not considered appropriate. • The decision also appeared influenced by a perception that the ambulance provided appropriate access to the ED which was considered most appropriate for their particular condition (too severe to go elsewhere, all facilities in one spot, better specialised and better care). • In 43.8% of cases a health care professional advised use of the ambulance. • Only a small number of people perceived that ambulance should be freely available regardless of severity or appropriateness. These findings confirm a growing understanding that the choice of professional emergency health care services is not made lightly but rather made by reasonable people exercising a judgement which is influenced by public awareness of the risks of acute health and which is most often informed by health professionals. It is also made on the basis of a rational weighing up of alternatives and a deliberate and considered choice to seek assistance from a service which the patient perceived was most appropriate to their needs at that time. These findings add weight to dispensing with public perceptions that ED and ambulance congestion is a result of inappropriate choice by patients. The challenge for health services is to better understand the patient’s needs and to design and validate services that meet those needs. The failure of our health system to do so should not be grounds for blaming the patient, claiming inappropriate patient choices.

Quantitative proteomic approach to study subcellular localization of membrane proteins

As proteins within cells are spatially organized according to their role, knowledge about protein localization gives insight into protein function. Here, we describe the LOPIT technique (localization of organelle proteins by isotope tagging) developed for the simultaneous and confident determination of the steady-state distribution of hundreds of integral membrane proteins within organelles. The technique uses a partial membrane fractionation strategy in conjunction with quantitative proteomics. Localization of proteins is achieved by measuring their distribution pattern across the density gradient using amine-reactive isotope tagging and comparing these patterns with those of known organelle residents. LOPIT relies on the assumption that proteins belonging to the same organelle will co-fractionate. Multivariate statistical tools are then used to group proteins according to the similarities in their distributions, and hence localization without complete centrifugal separation is achieved. The protocol requires approximately 3 weeks to complete and can be applied in a high-throughput manner to material from many varied sources.

DRB2 is required for microRNA biogenesis in Arabidopsis thaliana

Background The Arabidopsis thaliana (Arabidopsis) DOUBLE-STRANDED RNA BINDING (DRB) protein family consists of five members, DRB1 to DRB5. The biogenesis of two developmentally important small RNA (sRNA) species, the microRNAs (miRNAs) and trans-acting small interfering RNAs (tasiRNAs) by DICER-LIKE (DCL) endonucleases requires the assistance of DRB1 and DRB4 respectively. The importance of miRNA-directed target gene expression in plant development is exemplified by the phenotypic consequence of loss of DRB1 activity (drb1 plants). Principal Findings Here we report that the developmental phenotype of the drb235 triple mutant plant is the result of deregulated miRNA biogenesis in the shoot apical meristem (SAM) region. The expression of DRB2, DRB3 and DRB5 in wild-type seedlings is restricted to the SAM region. Small RNA sequencing of the corresponding tissue of drb235 plants revealed altered miRNA accumulation. Approximately half of the miRNAs detected remained at levels equivalent to those of wild-type plants. However, the accumulation of the remaining miRNAs was either elevated or reduced in the triple mutant. Examination of different single and multiple drb mutants revealed a clear association between the loss of DRB2 activity and altered accumulation for both the elevated and reduced miRNA classes. Furthermore, we show that the constitutive over-expression of DRB2 outside of its wild-type expression domain can compensate for the loss of DRB1 activity in drb1 plants. Conclusions/Significance Our results suggest that in the SAM region, DRB2 is both antagonistic and synergistic to the role of DRB1 in miRNA biogenesis, adding an additional layer of gene regulatory complexity in this developmentally important tissue.

Atomistic simulation of interfacial behaviour in graphene-polymer nanocomposites

Graphene–polymer nanocomposites have promising properties as new structural and functional materials. The remarkable mechanical property enhancement in these nanocomposites is generally attributed to exceptional mechanical property of graphene and possible load transfer between graphene and polymer matrix. However, the underlying strengthening and toughening mechanisms have not been well understood. In this work, the interfacial behavior of graphene-polyethylene (PE) was investigated using molecular dynamics (MD) method. The interfacial shear force (ISF) and interfacial shear stress (ISS) between graphene and PE matrix were evaluated, taking into account graphene size, the number of graphene layers and the structural defects in graphene. MD results show that the ISS at graphene-PE interface mainly distributes at each end of the graphene nanofiller within the range of 1 nm, and much larger than that at carbon nanotube (CNT)-PE interface. Moreover, it was found that the ISS at graphene-PE interface is sensitive to the layer number.

Managing health risks of extreme weather events : need for a systematic approach

The Climate Commission recently outlined the trend of major extreme weather events in different regions of Australia, including heatwaves, floods, droughts, bushfires, cyclones and storms. These events already impose an enormous health and financial burden onto society and are projected to occur more frequently and intensely. Unless we act now, further financial losses and increasing health burdens seem inevitable. We seek to highlight the major areas for interdisciplinary investigation, identify barriers and formulate response strategies.

An investigation of schizotypy in injecting amphetamine users

A fully dimensional view of psychiatric disorder conceptualises schizotypy as both a continuous personality trait and an underlying vulnerability to the development of psychotic illness. Such a model would predict that the structure of schizotypal traits would closely parallel the structure of schizophrenia or psychosis. This was investigated in injecting amphetamine users (N = 322), a clinical population who have high rates of acute psychotic episodes and subclinical schizotypal experiences. Schizotypy was assessed using the Oxford-Liverpool Inventory of Feelings and Experiences (O-LIFE), and psychotic symptoms were assessed using the Brief Psychiatric Rating Scale (BPRS). Using confirmatory factor analysis, O-LIFE subscale scores were mapped onto latent variables with their more clinical counterparts from the BPRS. A four-factor model comprising positive schizotypy, disorganisation, negative schizotypy, and disinhibition provided the best model fit, consistent with prior research into the structure of schizotypy. The model provided a good fit to the data, lending support to the theory that schizotypy and psychotic symptoms map onto common underlying dimensions.

The Implications of Activity Based Funding for Emergency Departments : A Comprehensive Literature Review

Executive Summary Emergency Departments (EDs) locally, nationally and internationally are becoming increasingly busy. Within this context, it can be challenging to deliver a health service that is safe, of high quality and cost-effective. Whilst various models are described within the literature that aim to measure ED ‘work’ or ‘activity’, they are often not linked to a measure of costs to provide such activity. It is important for hospital and ED managers to understand and apply this link so that optimal staffing and financial resourcing can be justifiably sought. This research is timely given that Australia has moved towards a national Activity Based Funding (ABF) model for ED activity. ABF is believed to increase transparency of care and fairness (i.e. equal work receives equal pay). ABF involves a person-, performance- or activity-based payment system, and thus a move away from historical “block payment” models that do not incentivise efficiency and quality. The aim of the Statewide Workforce and Activity-Based Funding Modelling Project in Queensland Emergency Departments (SWAMPED) is to identify and describe best practice Emergency Department (ED) workforce models within the current context of ED funding that operates under an ABF model. The study is comprised of five distinct phases. This monograph (Phase 1) comprises a systematic review of the literature that was completed in June 2013. The remaining phases include a detailed survey of Queensland hospital EDs’ resource levels, activity and operational models of care, development of new resource models, development of a user-friendly modelling interface for ED mangers, and production of a final report that identifies policy implications. The anticipated deliverable outcome of this research is the development of an ABF based Emergency Workforce Modelling Tool that will enable ED managers to profile both their workforce and operational models of care. Additionally, the tool will assist with the ability to more accurately inform adequate staffing numbers required in the future, inform planning of expected expenditures and be used for standardisation and benchmarking across similar EDs. Summary of the Findings Within the remit of this review of the literature, the main findings include: 1. EDs are becoming busier and more congested Rising demand, barriers to ED throughput and transitions of care all contribute to ED congestion. In addition requests by organisational managers and the community require continued broadening of the scope of services required of the ED and further increases in demand. As the population live longer with more lifestyle diseases their propensity to require ED care continues to grow. 2. Various models of care within EDs exist Models often vary to account for site specific characteritics to suit staffing profile, ED geographical location (e.g. metropolitan or rural site), and patient demographic profile (e.g. paediatrics, older persons, ethnicity). Existing and new models implemented within EDs often depend on the target outcome requiring change. Generally this is focussed on addressing issues at the input, throughput or output areas of the ED. Even with models targeting similar demographic or illness, the structure and process elements underpinning the model can vary, which can impact on outcomes and variance to the patient and carer experience between and within EDs. Major models of care to manage throughput inefficiencies include: A. Workforce Models of Care focus on the appropriate level of staffing for a given workload to provide prompt, timely and clinically effective patient care within an emergency care setting. The studies reviewed suggest that the early involvement of senior medical decision maker and/or specialised nursing roles such as Emergency Nurse Practitioners and Clinical Initiatives Nurse, primary contact or extended scope Allied Health Practitioners can facilitate patient flow and improve key indicators such as length of stay and reducing the number of those who did not wait to be seen amongst others. B. Operational Models of Care within EDs focus on mechanisms for streaming (e.g. fast-tracking) or otherwise grouping patient care based on acuity and complexity to assist with minimising any throughput inefficiencies. While studies support the positive impact of these models in general, it appears that they are most effective when they are adequately resourced. 3. Various methods of measuring ED activity exist Measuring ED activity requires careful consideration of models of care and staffing profile. Measuring activity requires the ability to account for factors including: patient census, acuity, LOS, intensity of intervention, department skill-mix plus an adjustment for non-patient care time. 4. Gaps in the literature Continued ED growth calls for new and innovative care delivery models that are safe, clinically effective and cost effective. New roles and stand-alone service delivery models are often evaluated in isolation without considering the global and economic impact on staffing profiles. Whilst various models of accounting for and measuring health care activity exist, costing studies and cost effectiveness studies are lacking for EDs making accurate and reliable assessments of care models difficult. There is a necessity to further understand, refine and account for measures of ED complexity that define a workload upon which resources and appropriate staffing determinations can be made into the future. There is also a need for continued monitoring and comprehensive evaluation of newly implemented workforce modelling tools. This research acknowledges those gaps and aims to: • Undertake a comprehensive and integrated whole of department workforce profiling exercise relative to resources in the context of ABF. • Inform workforce requirements based on traditional quantitative markers (e.g. volume and acuity) combined with qualitative elements of ED models of care; • Develop a comprehensive and validated workforce calculation tool that can be used to better inform or at least guide workforce requirements in a more transparent manner.

Paint spray mass spectrometry for the detection of additives from polymers on conducting surfaces

Paint Spray is developed as a direct sampling ionisation method for mass spectrometric analysis of additives in polymer-based surface coatings. The technique simply involves applying an external high voltage (5 kV) to the wetted sample placed in front of the mass spectrometer inlet and represents a much simpler ionisation technique compared to those currently available. The capabilities of Paint Spray are demonstrated herein with the detection of four commercially available hindered amine light stabilisers; TINUVIN® 770, TINUVIN® 292, TINUVIN® 123 and TINUVIN® 152 directly from thermoset polyester-based coil coatings. Paint Spray requires no sample preparation or pre-treatment and combined with its simplicity - requiring no specialised equipment - makes it ideal for use by non-specialists. The application of Paint Spray for industrial use has significant potential as sample collection from a coil coating production line and Paint Spray ionisation could enable fast quality control screening at high sensitivity.

Ambient ionisation mass spectrometry for the characterisation of polymers and polymer additives : A review

The purpose of this review is to showcase the present capabilities of ambient sampling and ionisation technologies for the analysis of polymers and polymer additives by mass spectrometry (MS) while simultaneously highlighting their advantages and limitations in a critical fashion. To qualify as an ambient ionisation technique, the method must be able to probe the surface of solid or liquid samples while operating in an open environment, allowing a variety of sample sizes, shapes, and substrate materials to be analysed. The main sections of this review will be guided by the underlying principle governing the desorption/extraction step of the analysis; liquid extraction, laser ablation, or thermal desorption, and the major component investigated, either the polymer itself or exogenous compounds (additives and contaminants) present within or on the polymer substrate. The review will conclude by summarising some of the challenges these technologies still face and possible directions that would further enhance the utility of ambient ionisation mass spectrometry as a tool for polymer analysis. (C) 2013 Elsevier B. V. All rights reserved.

Sustaining social innovation enterprises through a design led innovation framework

Constant changes in the global economic environment require companies to revisit traditional assumptions about how businesses create and capture value (Teece, 2010). In recent years, management practice literature has focused largely on better understanding business models and business model innovation (Amit, Zott and Massa, 2010; Johnson, Christensen and Kagermann, 2008). Much has been written on the benefits of linking design and design thinking to organisational strategies and business transformation. However, very little has been researched and reported on regarding the impact of design led approaches to triple bottom-line opportunities such as, social innovation enterprise. In the context of this paper Design Led Innovation is defined as the tools and approaches which enable design thinking to be embedded as an element of cultural transformation within a business. Being Design Led requires a company to have a vision for top line growth founded on deep customer insights and expanded through customer and stakeholder engagements. The outcomes of this are then mapped to all aspects of the business, enabling the vision to be successfully implemented and achieved. It is the latter part of this definition where we believe Design Led Innovation has the greatest value in transforming social innovation enterprise into a sustainable business venture. However, we also acknowledge that enabling these firms to think strategically about their business model is difficult given the unique operational and funding challenges that often characterize many social enterprises. The purpose of this paper, therefore, is to pose the question, do sustainable innovation enterprise innovate their business model? And if so, how? It is the authors’ opinion that such enterprises only innovate at the product or system level without a complete understanding of the business model structure, which underpins the long term viability. However, in this paper we challenge this notion and explore if such firms can overcome their size and operational constraints to become sustainable enterprises using a design led approach. This is achieved through contextualizing business model innovation, briefly defining social innovation enterprise and profiling a new and emerging industry in Australia – Clean Technology. Future research challenges and opportunities are also presented.

The impact of heatwaves on emergency department visits in Brisbane, Australia : a time series study

Introduction The acute health effects of heatwaves in a subtropical climate and their impact on emergency departments (ED) are not well known. The purpose of this study is to examine overt heat-related presentations to EDs associated with heatwaves in Brisbane. Methods Data were obtained for the summer seasons (December to February) from 2000-2012. Heatwave events were defined as two or more successive days with daily maximum temperature >=34[degree sign]C (HWD1) or >=37[degree sign]C (HWD2). Poisson generalised additive model was used to assess the effect of heatwaves on heat-related visits (International Classification of Diseases (ICD) 10 codes T67 and X30; ICD 9 codes 992 and E900.0). Results Overall, 628 cases presented for heat-related illnesses. The presentations significantly increased on heatwave days based on HWD1 (relative risk (RR) = 4.9, 95% confidence interval (CI): 3.8, 6.3) and HWD2 (RR = 18.5, 95% CI: 12.0, 28.4). The RRs in different age groups ranged between 3-9.2 (HWD1) and 7.5-37.5 (HWD2). High acuity visits significantly increased based on HWD1 (RR = 4.7, 95% CI: 2.3, 9.6) and HWD2 (RR = 81.7, 95% CI: 21.5, 310.0). Average length of stay in ED significantly increased by >1 hour (HWD1) and >2 hours (HWD2). Conclusions Heatwaves significantly increase ED visits and workload even in a subtropical climate. The degree of impact is directly related to the extent of temperature increases and varies by socio-demographic characteristics of the patients. Heatwave action plans should be tailored according to the population needs and level of vulnerability. EDs should have plans to increase their surge capacity during heatwaves.

Direct detection of additives and degradation products from polymers by liquid extraction surface analysis employing chip-based nanospray mass spectrometry

RATIONALE: Polymer-based surface coatings in outdoor applications experience accelerated degradation due to exposure to solar radiation, oxygen and atmospheric pollutants. These deleterious agents cause undesirable changes to the aesthetic and mechanical properties of the polymer, reducing its lifetime. The use of antioxidants such as hindered amine light stabilisers (HALS) retards these degradative processes; however, mechanisms for HALS action and polymer degradation are poorly understood. METHODS: Detection of the HALS TINUVINW123 (bis(1-octyloxy-2,2,6,6-tetramethyl-4-piperidyl) sebacate) and the polymer degradation products directly from a polyester-based coil coating was achieved by liquid extraction surface analysis (LESA) coupled to a triple quadrupole QTRAPW 5500 mass spectrometer. The detection of TINUVINW123 and melamine was confirmed by the characteristic fragmentation pattern observed in LESA-MS/MS spectra that was identical to that reported for authentic samples. RESULTS: Analysis of an unstabilised coil coating by LESA-MS after exposure to 4 years of outdoor field testing revealed the presence of melamine (1,3,5-triazine-2,4,6-triamine) as a polymer degradation product at elevated levels. Changes to the physical appearance of the coil coating, including powder-like deposits on the coating's surface, were observed to coincide with melamine deposits and are indicative of the phenomenon known as polymer ' blooming'. CONCLUSIONS: For the first time, in situ detection of analytes from a thermoset polymer coating was accomplished without any sample preparation, providing advantages over traditional extraction-analysis approaches and some contemporary ambient MS methods. Detection of HALS and polymer degradation products such as melamine provides insight into the mechanisms by which degradation occurs and suggests LESA-MS is a powerful new tool for polymer analysis. Copyright (C) 2012 John Wiley & Sons, Ltd.

Genomic organisation, activity and distribution analysis of the microbial putrescine oxidase degradation pathway

The catalytic action of putrescine specific amine oxidases acting in tandem with 4-aminobutyraldehyde dehydrogenase is explored as a degradative pathway in Rhodococcus opacus. By limiting the nitrogen source, increased catalytic activity was induced leading to a coordinated response in the oxidative deamination of putrescine to 4-aminobutyraldehyde and subsequent dehydrogenation to 4-aminobutyrate. Isolating the dehydrogenase by ion exchange chromatography and gel filtration revealed that the enzyme acts principally on linear aliphatic aldehydes possessing an amino moiety. Michaelis-Menten kinetic analysis delivered a Michaelis constant (KM=0.014mM) and maximum rate (Vmax=11.2μmol/min/mg) for the conversion of 4-aminobutyraldehyde to 4-aminobutyrate. The dehydrogenase identified by MALDI-TOF mass spectrometric analysis (E value=0.031, 23% coverage) belongs to a functionally related genomic cluster that includes the amine oxidase, suggesting their association in a directed cell response. Key regulatory, stress and transport encoding genes have been identified, along with candidate dehydrogenases and transaminases for the further conversion of 4-aminobutyrate to succinate. Genomic analysis has revealed highly similar metabolic gene clustering among members of Actinobacteria, providing insight into putrescine degradation notably among Micrococcaceae, Rhodococci and Corynebacterium by a pathway that was previously uncharacterised in bacteria.

4-(4-Aminophenylsulfonyl)anilinium toluene-4-sulfonate

In the title p-toluenesulfonate salt of the drug dapsone, C12H13N2O2S+ C7H7O3S-, the dihedral angle between the two aromatic rings of the dapsone monocation is 70.19(17)deg. and those between these rings and that of the p-toluenesulfonate anion are 72.34(17) and 46.43(17)deg. All amine and aminium H-atoms are involved in intermolecular N-H...O hydrogen-bonding associations with sulfonyl O-atom acceptors as well as one of the sulfone O-atoms, giving a three-dimensional structure.

Poly[di-mu-aqua-bis{2-amino-4-nitrobenzoato)]-dirubidium

In the structure of title compound [Rb2(C7H5N2O4)2(H2O)2]n the asymmetric unit comprises two independent and different seven-coordinate Rb centres, one RbO7, the other RbO6N, with both having irregular stereochemistry. The RbO7 coordination comprises bridging oxygen donors from two water molecules, three carboxylate groups, and a nitro group, with one doubly bridging. The RbO6N coordination comprises the two bridging water molecules, one monodentate amine N donor, one carboxyl O donor and three O donors from nitro groups (one from the chelate bridge). The extension of the dinuclear unit gives a three-dimensional polymeric structure which is stabilized by both intra- and intermolecular amine N-H...O and water O-H...O hydrogen bonds to carboxyl and water O-atom acceptors, as well as a number of inter-ring \p--\p interactions [minimum ring centroid separation, 3.364(2) \%A]. This complex is both isostructural with the analogous Cs -nitroanthranilate monohydrate complex.