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.

Carbon nanotube composite sensor for structural health monitoring of bridge structures

Bridges are important infrastructures of all nations and are required for transportation of goods as well as human. A catastrophic failure can result in loss of lives and enormous financial hardship to the nation. Although various kinds of sensors are now available to monitor the health of the structures due to corrosion, they do not provide permanent and long term measurements. This paper investigates the fabrication of Carbon Nanotube (CNT) based composite sensors for corrosion detection of structures. Multi-wall CNT (MWCNT)/Nafion composite sensors were fabricated to evaluate their electrical properties for corrosion detection. The test specimens were subjected to real life corrosion experimental tests and the results confirm that the electrical resistance of the sensor electrode was dramatically changed due to corrosion.

Acoustic emission condition monitoring : an application for wind turbine fault detection

Low speed rotating machines which are the most critical components in drive train of wind turbines are often menaced by several technical and environmental defects. These factors contribute to mount the economic requirement for Health Monitoring and Condition Monitoring of the systems. When a defect is happened in such system result in reduced energy loss rates from related process and due to it Condition Monitoring techniques that detecting energy loss are very difficult if not possible to use. However, in the case of Acoustic Emission (AE) technique this issue is partly overcome and is well suited for detecting very small energy release rates. Acoustic Emission (AE) as a technique is more than 50 years old and in this new technology the sounds associated with the failure of materials were detected. Acoustic wave is a non-stationary signal which can discover elastic stress waves in a failure component, capable of online monitoring, and is very sensitive to the fault diagnosis. In this paper the history and background of discovering and developing AE is discussed, different ages of developing AE which include Age of Enlightenment (1950-1967), Golden Age of AE (1967-1980), Period of Transition (1980-Present). In the next section the application of AE condition monitoring in machinery process and various systems that applied AE technique in their health monitoring is discussed. In the end an experimental result is proposed by QUT test rig which an outer race bearing fault was simulated to depict the sensitivity of AE for detecting incipient faults in low speed high frequency machine.

Experimental evaluation of an autonomous surface vehicle for water quality and greenhouse gas emission monitoring

This paper describes the experimental evaluation of a novel Autonomous Surface Vehicle capable of navigating complex inland water reservoirs and measuring a range of water quality properties and greenhouse gas emissions. The 16 ft long solar powered catamaran is capable of collecting water column profiles whilst in motion. It is also directly integrated with a reservoir scale floating sensor network to allow remote mission uploads, data download and adaptive sampling strategies. This paper describes the onboard vehicle navigation and control algorithms as well as obstacle avoidance strategies. Experimental results are shown demonstrating its ability to maintain track and avoid obstacles on a variety of large-scale missions and under differing weather conditions, as well as its ability to continuously collect various water quality parameters complimenting traditional manual monitoring campaigns.

An autonomous surface vehicle for water quality monitoring

This paper describes a novel Autonomous Surface Vehicle capable of navigating throughout complex inland water storages and measuring a range of water quality properties and greenhouse gas emissions. The 16 ft long solar powered catamaran can collect this information throughout the water column whilst the vehicle is moving. A unique feature of this ASV is its integration into a storage scale floating sensor network to allow remote mission uploads, data download and adaptive sampling strategies. This paper provides an overview of the vehicle design and operation including control, laser-based obstacle avoidance, and vision-based inspection capabilities. Experimental results are shown illustrating its ability to continuously collect key water quality parameters and compliment intensive manual monitoring campaigns.

Is age a factor in the success or failure of remote monitoring in heart failure? Telemonitoring and structured telephone support in elderly heart failure patients

Background There are few data regarding the effectiveness of remote monitoring for older people with heart failure. We conducted a post-hoc sub-analysis of a previously published large Cochrane systematic review and meta-analysis of relevant randomized controlled trials to determine whether structured telephone support and telemonitoring were effective in this population. Methods A post hoc sub-analysis of a systematic review and meta-analysis that applied the Cochrane methodology was conducted. Meta-analyses of all-cause mortality, all-cause hospitalizations and heart failure-related hospitalizations were performed for studies where the mean or median age of participants was 70 or more years. Results The mean or median age of participants was 70 or more years in eight of the 16 (n=2,659/5,613; 47%) structured telephone support studies and four of the 11 (n=894/2,710; 33%) telemonitoring studies. Structured telephone support (RR 0.80; 95% CI=0.63-1.00) and telemonitoring (RR 0.56; 95% CI=0.41-0.76) interventions reduced mortality. Structured telephone support interventions reduced heart failure-related hospitalizations (RR 0.81; 95% CI=0.67-0.99). Conclusion Despite a systematic bias towards recruitment of individuals younger than the epidemiological average into the randomized controlled trials, older people with heart failure did benefit from structured telephone support and telemonitoring. These post-hoc sub-analysis results were similar to overall effects observed in the main meta-analysis. While further research is required to confirm these observational findings, the evidence at hand indicates that discrimination by age alone may be not be appropriate when inviting participation in a remote monitoring service for heart failure.

Managing and analysing big audio data for environmental monitoring

Environmental monitoring is becoming critical as human activity and climate change place greater pressures on biodiversity, leading to an increasing need for data to make informed decisions. Acoustic sensors can help collect data across large areas for extended periods making them attractive in environmental monitoring. However, managing and analysing large volumes of environmental acoustic data is a great challenge and is consequently hindering the effective utilization of the big dataset collected. This paper presents an overview of our current techniques for collecting, storing and analysing large volumes of acoustic data efficiently, accurately, and cost-effectively.

Back to the roots : mean-variance analysis of relevance estimations

Recently, mean-variance analysis has been proposed as a novel paradigm to model document ranking in Information Retrieval. The main merit of this approach is that it diversifies the ranking of retrieved documents. In its original formulation, the strategy considers both the mean of relevance estimates of retrieved documents and their variance. How- ever, when this strategy has been empirically instantiated, the concepts of mean and variance are discarded in favour of a point-wise estimation of relevance (to replace the mean) and of a parameter to be tuned or, alternatively, a quantity dependent upon the document length (to replace the variance). In this paper we revisit this ranking strategy by going back to its roots: mean and variance. For each retrieved document, we infer a relevance distribution from a series of point-wise relevance estimations provided by a number of different systems. This is used to compute the mean and the variance of document relevance estimates. On the TREC Clueweb collection, we show that this approach improves the retrieval performances. This development could lead to new strategies to address the fusion of relevance estimates provided by different systems.

Mapping, monitoring, and modelling of hazardous waste sites

Management of the industrial nations' hazardous waste is a current and exponentially increasing, global threatening situation. Improved environmental information must be obtained and managed concerning the current status, temporal dynamics and potential future status of these critical sites. To test the application of spatial environmental techniques to the problem of hazardous waste sites, as Superfund (CERCLA) test site was chosen in an industrial/urban valley experiencing severe TCE, PCE, and CTC ground water contamination. A paradigm is presented for investigating spatial/environmental tools available for the mapping, monitoring and modelling of the environment and its toxic contaminated plumes. This model incorporates a range of technical issues concerning the collection of data as augmented by remotely sensed tools, the format and storage of data utilizing geographic information systems, and the analysis and modelling of environment through the use of advance GIS analysis algorithms and geophysic models of hydrologic transport including statistical surface generation. This spatial based approach is evaluated against the current government/industry standards of operations. Advantages and lessons learned of the spatial approach are discussed.

Wetlands : a perspective for mapping, monitoring, and modeling

Experience gained from numerous projects conducted by the U.S. Environmental Protection Agency's (EPA) Environmental Monitoring Systems Laboratory in Las Vegas, Nevada has provided insight to functional issues of mapping, monitoring, and modeling of wetland habitats. Three case studies in poster form describe these issues pertinent to managing wetland resources as mandated under Federal laws. A multiphase project was initiated by the EPA Alaska operations office to provide detailed wetland mapping of arctic plant communities in an area under petroleum development pressure. Existing classification systems did not meet EPA needs. Therefore a Habitat Classification System (HCS) derived from aerial photography was compiled. In conjunction with this photointerpretive keys were developed. These products enable EPA personnel to map large inaccessible areas of the arctic coastal plain and evaluate the sensitivity of various wetland habitats relative to petroleum development needs.

Classification of cancer-related death certificates using machine learning

Background Cancer monitoring and prevention relies on the critical aspect of timely notification of cancer cases. However, the abstraction and classification of cancer from the free-text of pathology reports and other relevant documents, such as death certificates, exist as complex and time-consuming activities. Aims In this paper, approaches for the automatic detection of notifiable cancer cases as the cause of death from free-text death certificates supplied to Cancer Registries are investigated. Method A number of machine learning classifiers were studied. Features were extracted using natural language techniques and the Medtex toolkit. The numerous features encompassed stemmed words, bi-grams, and concepts from the SNOMED CT medical terminology. The baseline consisted of a keyword spotter using keywords extracted from the long description of ICD-10 cancer related codes. Results Death certificates with notifiable cancer listed as the cause of death can be effectively identified with the methods studied in this paper. A Support Vector Machine (SVM) classifier achieved best performance with an overall F-measure of 0.9866 when evaluated on a set of 5,000 free-text death certificates using the token stem feature set. The SNOMED CT concept plus token stem feature set reached the lowest variance (0.0032) and false negative rate (0.0297) while achieving an F-measure of 0.9864. The SVM classifier accounts for the first 18 of the top 40 evaluated runs, and entails the most robust classifier with a variance of 0.001141, half the variance of the other classifiers. Conclusion The selection of features significantly produced the most influences on the performance of the classifiers, although the type of classifier employed also affects performance. In contrast, the feature weighting schema created a negligible effect on performance. Specifically, it is found that stemmed tokens with or without SNOMED CT concepts create the most effective feature when combined with an SVM classifier.

Health monitoring of short-and medium-spen bridges using an improved modal strain energy method

Increasing the importance and use of infrastructures such as bridges, demands more effective structural health monitoring (SHM) systems. SHM has well addressed the damage detection issues through several methods such as modal strain energy (MSE). Many of the available MSE methods either have been validated for limited type of structures such as beams or their performance is not satisfactory. Therefore, it requires a further improvement and validation of them for different types of structures. In this study, an MSE method was mathematically improved to precisely quantify the structural damage at an early stage of formation. Initially, the MSE equation was accurately formulated considering the damaged stiffness and then it was used for derivation of a more accurate sensitivity matrix. Verification of the improved method was done through two plane structures: a steel truss bridge and a concrete frame bridge models that demonstrate the framework of a short- and medium-span of bridge samples. Two damage scenarios including single- and multiple-damage were considered to occur in each structure. Then, for each structure, both intact and damaged, modal analysis was performed using STRAND7. Effects of up to 5 per cent noise were also comprised. The simulated mode shapes and natural frequencies derived were then imported to a MATLAB code. The results indicate that the improved method converges fast and performs well in agreement with numerical assumptions with few computational cycles. In presence of some noise level, it performs quite well too. The findings of this study can be numerically extended to 2D infrastructures particularly short- and medium-span bridges to detect the damage and quantify it more accurately. The method is capable of providing a proper SHM that facilitates timely maintenance of bridges to minimise the possible loss of lives and properties.

Soil moisture monitoring at the field scale using neutron probe

Measurement of the moisture variation in soils is required for geotechnical design and research because soil properties and behavior can vary as moisture content changes. The neutron probe, which was developed more than 40 years ago, is commonly used to monitor soil moisture variation in the field. This study reports a full-scale field monitoring of soil moisture using a neutron moisture probe for a period of more than 2 years in the Melbourne (Australia) region. On the basis of soil types available in the Melbourne region, 23 sites were chosen for moisture monitoring down to a depth of 1500 mm. The field calibration method was used to develop correlations relating the volumetric moisture content and neutron counts. Observed results showed that the deepest “wetting front” during the wet season was limited to the top 800 to 1000 mm of soil whilst the top soil layer down to about 550mmresponded almost immediately to the rainfall events. At greater depths (550 to 800mmand below 800 mm), the moisture variations were relatively low and displayed predominantly periodic fluctuations. This periodic nature was captured with Fourier analysis to develop a cyclic moisture model on the basis of an analytical solution of a one-dimensional moisture flow equation for homogeneous soils. It is argued that the model developed can be used to predict the soil moisture variations as applicable to buried structures such as pipes.

Monitoring phase behavior of sub- and supercritical CO2 confined in porous fractal silica with 85% porosity

Phase behavior of CO2 confined in porous fractal silica with volume fraction of SiO2 φs = 0.15 was investigated using small-angle neutron scattering (SANS) and ultrasmall-angle neutron scattering (USANS) techniques. The range of fluid densities (0<(FCO2)bulk<0.977 g/cm3) and temperatures (T=22 °C, 35 and 60 °C) corresponded to gaseous, liquid, near critical and supercritical conditions of the bulk fluid. The results revealed formation of a dense adsorbed phase in small pores with sizes D<40 A° at all temperatures. At low pressure (P <55 bar, (FCO2)bulk <0.2 g/cm3) the average fluid density in pores may exceed the density of bulk fluid by a factor up to 6.5 at T=22 °C. This “enrichment factor” gradually decreases with temperature, however significant fluid densification in small pores still exists at temperature T=60°C, i.e., far above the liquid-gas critical temperature of bulk CO2 (TC=31.1 °C). Larger pores are only partially filled with liquid-like adsorbed layer which coexists with unadsorbed fluid in the pore core. With increasing pressure, all pores become uniformly filled with the fluid, showing no measurable enrichment or depletion of the porous matrix with CO2.

On-line scale monitoring device

Developments in evaporator cleaning have accelerated in the past 10 years as a result of an extended period of research into scale formation and scale composition. Chemical cleaning still provides the most cost effective method of cleaning the evaporators. The paper describes a system that was designed to obtain on-line samples of evaporator scale negating the need to open up hot evaporator vessels for scale collection. This system was successfully implemented in a number of evaporators at a sugar mill. This paper also describes a recent experience in a sugar factory in which the cleaning procedure was slightly modified, resulting in effective removal of intractable scale.