Part 2. Chemical and physical restraints in the management of mechanically ventilated patients in the ICU: A patient perspective

An important goal of the care for the mechanically ventilated patient is to minimize patient discomfort and anxiety. This is partly achieved by frequent use of chemical and physical restraints. The majority of patients in intensive care will receive some form of sedation. The goal and use of sedation has changed considerably over the past few decades with literature evidencing trends toward overall lighter sedation levels and daily interruption of sedation. Conversely, the use of physical restraint for the ventilated patient in ICU differs considerably between nations and continents. A large portion of the literature on the use of physical restraint is from general hospital wards and residential homes, and not from the ICU environment. Recent literature suggests minimal use of physical restraint in the ICU, and that reduction programmes have been initiated. However, very few papers illuminate the patient's experience of physical and chemical restraints as a treatment strategy. In Part 1 of this two-part review, the evidence on chemical and physical restraints was explored with specific focus on definitions of terms, unplanned extubation, agitation, delirium as well as the impact of nurse–patient ratios in the ICU on these issues. This paper, Part 2, examines the evidence related to chemical and physical restraints from the mechanically ventilated patient's perspective.

Assessing the effectiveness of water sensitive urban design in Southeast Queensland

Water Sensitive Urban Design (WSUD) systems have the potential mitigate the hydrologic disturbance and water quality concerns associated with stormwater runoff from urban development. In the last few years WSUD has been strongly promoted in South East Queensland (SEQ) and new developments are now required to use WSUD systems to manage stormwater runoff. However, there has been limited field evaluation of WSUD systems in SEQ and consequently knowledge of their effectiveness in the field, under storm events, is limited. The objective of this research project was to assess the effectiveness of WSUD systems installed in a residential development, under real storm events. To achieve this objective, a constructed wetland, bioretention swale and a bioretention basin were evaluated for their ability to improve the hydrologic and water quality characteristics of stormwater runoff from urban development. The monitoring focused on storm events, with sophisticated event monitoring stations measuring the inflow and outflow from WSUD systems. Data analysis undertaken confirmed that the constructed wetland, bioretention basin and bioretention swale improved the hydrologic characteristics by reducing peak flow. The bioretention systems, particularly the bioretention basin also reduced the runoff volume and frequency of flow, meeting key objectives of current urban stormwater management. The pollutant loads were reduced by the WSUD systems to above or just below the regional guidelines, showing significant reductions to TSS (70-85%), TN (40-50%) and TP (50%). The load reduction of NOx and PO4 3- by the bioretention basin was poor (<20%), whilst the constructed wetland effectively reduced the load of these pollutants in the outflow by approximately 90%. The primary reason for the load reduction in the wetland was due to a reduction in concentration in the outflow, showing efficient treatment of stormwater by the system. In contrast, the concentration of key pollutants exiting the bioretention basin were higher than the inflow. However, as the volume of stormwater exiting the bioretention basin was significantly lower than the inflow, a load reduction was still achieved. Calibrated MUSIC modelling showed that the bioretention basin, and in particular, the constructed wetland were undersized, with 34% and 62% of stormwater bypassing the treatment zones in the devices. Over the long term, a large proportion of runoff would not receive treatment, considerably reducing the effectiveness of the WSUD systems.

Shear behaviour and design of LiteSteel beams

OneSteel Australian Tube Mills has recently developed a new hollow flange channel cold-formed section, known as the LiteSteel Beam (LSB). The innovative LSB sections have the beneficial characteristics of torsionally rigid closed rectangular flanges combined with economical fabrication processes from a single strip of high strength steel. They combine the stability of hot-rolled steel sections with the high strength to weight ratio of conventional cold-formed steel sections. The LSB sections are commonly used as flexural members in residential, industrial and commercial buildings. In order to ensure safe and efficient designs of LSBs, many research studies have been undertaken on the flexural behaviour of LSBs. However, no research has been undertaken on the shear behaviour of LSBs. Therefore this thesis investigated the ultimate shear strength behaviour of LSBs with and without web openings including their elastic buckling and post-buckling characteristics using both experimental and finite element analyses, and developed accurate shear design rules. Currently the elastic shear buckling coefficients of web panels are determined by assuming conservatively that the web panels are simply supported at the junction between the web and flange elements. Therefore finite element analyses were conducted first to investigate the elastic shear buckling behaviour of LSBs to determine the true support condition at the junction between their web and flange elements. An equation for the higher elastic shear buckling coefficient of LSBs was developed and included in the shear capacity equations in the cold-formed steel structures code, AS/NZS 4600. Predicted shear capacities from the modified equations and the available experimental results demonstrated the improvements to the shear capacities of LSBs due to the presence of higher level of fixity at the LSB flange to web juncture. A detailed study into the shear flow distribution of LSB was also undertaken prior to the elastic buckling analysis study. The experimental study of ten LSB sections included 42 shear tests of LSBs with aspect ratios of 1.0 and 1.5 that were loaded at midspan until failure. Both single and back to back LSB arrangements were used. Test specimens were chosen such that all three types of shear failure (shear yielding, inelastic and elastic shear buckling) occurred in the tests. Experimental results showed that the current cold-formed steel design rules are very conservative for the shear design of LSBs. Significant improvements to web shear buckling occurred due to the presence of rectangular hollow flanges while considerable post-buckling strength was also observed. Experimental results were presented and compared with corresponding predictions from the current design rules. Appropriate improvements have been proposed for the shear strength of LSBs based on AISI (2007) design equations and test results. Suitable design rules were also developed under the direct strength method (DSM) format. This thesis also includes the shear test results of cold-formed lipped channel beams from LaBoube and Yu (1978a), and the new design rules developed based on them using the same approach used with LSBs. Finite element models of LSBs in shear were also developed to investigate the ultimate shear strength behaviour of LSBs including their elastic and post-buckling characteristics. They were validated by comparing their results with experimental test results. Details of the finite element models of LSBs, the nonlinear analysis results and their comparisons with experimental results are presented in this thesis. Finite element analysis results showed that the current cold-formed steel design rules are very conservative for the shear design of LSBs. They also confirmed other experimental findings relating to elastic and post-buckling shear strength of LSBs. A detailed parametric study based on validated experimental finite element model was undertaken to develop an extensive shear strength data base and was then used to confirm the accuracy of the new shear strength equations proposed in this thesis. Experimental and numerical studies were also undertaken to investigate the shear behaviour of LSBs with web openings. Twenty six shear tests were first undertaken using a three point loading arrangement. It was found that AS/NZS 4600 and Shan et al.'s (1997) design equations are conservative for the shear design of LSBs with web openings while McMahon et al.'s (2008) design equation are unconservative. Experimental finite element models of LSBs with web openings were then developed and validated by comparing their results with experimental test results. The developed nonlinear finite element model was found to predict the shear capacity of LSBs with web opening with very good accuracy. Improved design equations have been proposed for the shear capacity of LSBs with web openings based on both experimental and FEA parametric study results. This thesis presents the details of experimental and numerical studies of the shear behaviour and strength of LSBs with and without web openings and the results including the developed accurate design rules.

Flexural behaviour and design of hollow flange steel beams

The LiteSteel Beam (LSB) is a new hollow flange channel section developed by OneSteel Australian Tube Mills using a patented Dual Electric Resistance Welding technique. The LSB has a unique geometry consisting of torsionally rigid rectangular hollow flanges and a relatively slender web. It is commonly used as rafters, floor joists and bearers and roof beams in residential, industrial and commercial buildings. It is on average 40% lighter than traditional hot-rolled steel beams of equivalent performance. The LSB flexural members are subjected to a relatively new Lateral Distortional Buckling mode, which reduces the member moment capacity. Unlike the commonly observed lateral torsional buckling of steel beams, lateral distortional buckling of LSBs is characterised by simultaneous lateral deflection, twist and web distortion. Current member moment capacity design rules for lateral distortional buckling in AS/NZS 4600 (SA, 2005) do not include the effect of section geometry of hollow flange beams although its effect is considered to be important. Therefore detailed experimental and finite element analyses (FEA) were carried out to investigate the lateral distortional buckling behaviour of LSBs including the effect of section geometry. The results showed that the current design rules in AS/NZS 4600 (SA, 2005) are over-conservative in the inelastic lateral buckling region. New improved design rules were therefore developed for LSBs based on both FEA and experimental results. A geometrical parameter (K) defined as the ratio of the flange torsional rigidity to the major axis flexural rigidity of the web (GJf/EIxweb) was identified as the critical parameter affecting the lateral distortional buckling of hollow flange beams. The effect of section geometry was then included in the new design rules using the new parameter (K). The new design rule developed by including this parameter was found to be accurate in calculating the member moment capacities of not only LSBs, but also other types of hollow flange steel beams such as Hollow Flange Beams (HFBs), Monosymmetric Hollow Flange Beams (MHFBs) and Rectangular Hollow Flange Beams (RHFBs). The inelastic reserve bending capacity of LSBs has not been investigated yet although the section moment capacity tests of LSBs in the past revealed that inelastic reserve bending capacity is present in LSBs. However, the Australian and American cold-formed steel design codes limit them to the first yield moment. Therefore both experimental and FEA were carried out to investigate the section moment capacity behaviour of LSBs. A comparison of the section moment capacity results from FEA, experiments and current cold-formed steel design codes showed that compact and non-compact LSB sections classified based on AS 4100 (SA, 1998) have some inelastic reserve capacity while slender LSBs do not have any inelastic reserve capacity beyond their first yield moment. It was found that Shifferaw and Schafer’s (2008) proposed equations and Eurocode 3 Part 1.3 (ECS, 2006) design equations can be used to include the inelastic bending capacities of compact and non-compact LSBs in design. As a simple design approach, the section moment capacity of compact LSB sections can be taken as 1.10 times their first yield moment while it is the first yield moment for non-compact sections. For slender LSB sections, current cold-formed steel codes can be used to predict their section moment capacities. It was believed that the use of transverse web stiffeners could improve the lateral distortional buckling moment capacities of LSBs. However, currently there are no design equations to predict the elastic lateral distortional buckling and member moment capacities of LSBs with web stiffeners under uniform moment conditions. Therefore, a detailed study was conducted using FEA to simulate both experimental and ideal conditions of LSB flexural members. It was shown that the use of 3 to 5 mm steel plate stiffeners welded or screwed to the inner faces of the top and bottom flanges of LSBs at third span points and supports provided an optimum web stiffener arrangement. Suitable design rules were developed to calculate the improved elastic buckling and ultimate moment capacities of LSBs with these optimum web stiffeners. A design rule using the geometrical parameter K was also developed to improve the accuracy of ultimate moment capacity predictions. This thesis presents the details and results of the experimental and numerical studies of the section and member moment capacities of LSBs conducted in this research. It includes the recommendations made regarding the accuracy of current design rules as well as the new design rules for lateral distortional buckling. The new design rules include the effects of section geometry of hollow flange steel beams. This thesis also developed a method of using web stiffeners to reduce the lateral distortional buckling effects, and associated design rules to calculate the improved moment capacities.

Adherence to nutrition supplements among patients with a fall-related lower limb fracture

Background The purpose of this study was to provide a detailed evaluation of adherence to nutrition supplements by patients with a lower limb fracture. Methods These descriptive data are from 49 nutritionally“ at-risk” patients aged 70+ years admitted to the hospital after a fall-related lower limb fracture and allocated to receive supplementation as part of a randomized, controlled trial. Supplementation commenced on day 7 and continued for 42 days. Prescribed volumes aimed to meet 45% of individually estimated theoretical energy requirements to meet the shortfall between literature estimates of energy intake and requirements. The supplement was administered by nursing staff on medication rounds in the acute or residential care settings and supervised through thrice-weekly home visits postdischarge. Results Median daily percent of the prescribed volume of nutrition supplement consumed averaged over the 42 days was 67% (interquartile range [IQR], 31–89, n = 49). There was no difference in adherence for gender, accommodation, cognition, or whether the supplement was self-administered or supervised. Twenty-three participants took some supplement every day, and a further 12 missed <5 days. For these 35 “nonrefusers,” adherence was 82% (IQR, 65–93), and they lost on average 0.7% (SD, 4.0%) of baseline weight over the 6 weeks of supplementation compared with a loss of 5.5% (SD, 5.4%) in the “refusers” (n = 14, 29%), p = .003. Conclusions We achieved better volume and energy consumption than previous studies of hip fracture patients but still failed to meet target supplement volumes prescribed to meet 45% of theoretical energy requirements. Clinicians should consider alternative methods of feeding such as a nasogastric tube, particularly in those patients where adherence to oral nutrition supplements is poor and dietary intake alone is insufficient to meet estimated energy requirements.

Voltage unbalance reduction in low voltage distribution networks with rooftop PVs

Voltage Unbalance (VU) is a power quality issue arising within the low voltage residential distribution networks due to the random location and rating of single-phase rooftop photovoltaic cells (PVs). In this paper, an analysis has been carried out to investigate how PV installations, their random location and power generation capacity can cause an increase in VU. Several efficient practical methods are discussed for VU reduction. Based on this analysis, it has been shown that the installation of a DSTATCOM can reduce VU. In this paper, the best possible location for DSTATCOM and its efficient control method to reduce VU will be presented. The results are verified through PSCAD/EMTDC and Monte Carlo simulations.

Measurement of standby power for selected electrical appliances in Australia

High growth in the uptake of electrical appliances is accounting for a significant increase in electricity consumption globally. In some developed countries, standby energy alone may account for about 10% of residential electricity use. The standby power for many appliances used in Australia is still well above the national goal of 1 W or less. In this paper, field measurements taken of standby power and operating power for a range of electrical appliances are presented. It was found that the difference between minimum value and maximum value of standby power could be quite large, up to 22.13 W for home theatre systems, for example. With the exception of home audio systems, however, the annual operating energy used by most electrical appliances was generally greater than the annual standby energy. Consumer behaviour and product choice can have a significant impact on standby power and operating power, which influences both energy demand and greenhouse gas emissions.

Examination of relationships between urban form, household activities, and time allocation in the Atlanta Metropolitan Region

A substantial body of research is focused on understanding the relationships between socio-demographics, land-use characteristics, and mode specific attributes on travel mode choice and time-use patterns. Residential and commercial densities, inter-mixing of land uses, and route directness in conjunction with transportation performance characteristics interact to influence accessibility to destinations as well as time spent traveling and engaging in activities. This study uniquely examines the activity durations undertaken for out-of-home subsistence; maintenance, and discretionary activities. Also examined are total tour durations (summing all activity categories within a tour). Cross-sectional activities are obtained from household activity travel survey data from the Atlanta Metropolitan Region. Time durations allocated to weekdays and weekends are compared. The censoring and endogeneity between activity categories and within individuals are captured using multiple equations Tobit models. The analysis and modeling reveal that land-use characteristics such as net residential density and the number of commercial parcels within a kilometer of a residence are associated with differences in weekday and weekend time-use allocations. Household type and structure are significant predictors across the three activity categories, but not for overall travel times. Tour characteristics such as time-of-day and primary travel mode of the tours also affect traveler's out-of-home activity-tour time-use patterns.

Adherence to medicines in the older-aged with chronic conditions : does an intervention concerning adherence by an allied health professional help?

Adherence to medicines is a major determinant of the effectiveness of medicines. However, estimates of non-adherence in the older-aged with chronic conditions vary from 40 to 75%. The problems caused by non-adherence in the older-aged include residential care and hospital admissions, progression of the disease, and increased costs to society. The reasons for non-adherence in the older-aged include items related to the medicine (e.g. cost, number of medicines, adverse effects) and those related to person (e.g. cognition, vision, depression). It is also known that there are many ways adherence can be increased (e.g. use of blister packs, cues). It is assumed that interventions by allied health professions, including a discussion of adherence, will improve adherence to medicines in the older aged but the evidence for this has not been reviewed. There is some evidence that telephone counselling about adherence by a nurse or pharmacist does improve adherence, short- and long-term. However, face-to-face intervention counselling at the pharmacy, or during a home visit by a pharmacist, has shown variable results with some studies showing improved adherence and some not. Education programs during hospital stays have not been shown to improve adherence on discharge, but education programs for subjects with hypertension have been shown to improve adherence. In combination with an education program, both counselling and a medicine review program have been shown to improve adherence short-term in the older-aged. Thus, there are many unanswered questions about the most effective interventions to promote adherence. More studies are needed to determine the most appropriate interventions by allied health professions, and these need to consider the disease state, demographics, and socio-economic status of the older-aged subject, and the intensity and duration of intervention needed.

Spatial analysis of melioidosis distribution in a suburban area

Burkholderia pseudomallei, the causative agent of melioidosis is associated with soil. This study used a geographic information system (GIS) to determine the spatial distribution of clinical cases of melioidosis in the endemic suburban region of Townsville in Australia. A total of 65 cases over the period 1996–2008 were plotted using residential address. Two distinct groupings were found. One was around the base of a hill in the city centre and the other followed the old course of a major waterway in the region. Both groups (accounting for 43 of the 65 cases examined) are in areas expected to have particularly wet topsoils following intense rainfall, due to soil type or landscape position.

The comparison of international and local sustainable assessment tools of landscape design for housing estate developments : case of Bangkok Metropolitan Region, Thailand

Various countries have been introducing sustainable assessment tools for real estate design to produce integrated sustainability components not just for the building, but also the landscape component of the development. This paper aims to present the comparison between international and local assessment tools of landscape design for housing estate developments in Bangkok Metropolitan Region (BMR), Thailand. The methodologies used are to review, then compare and identify discrepancy indicators among the tools. This paper will examine four international tools; LEED for Neighbourhood Development (LEED – ND) of United State of America (USA), EnviroDevelopment standards of Australia, Residential Landscape Sustainability of United Kingdom (UK) and Green Mark for Infrastructure of Singapore; and three BMR’s existing tools; Land Subdivision Act B.E. 2543, Environmental Impact Assessment Monitoring Awards (EIA-MA) and Thai’s Rating for Energy and Environmental Sustainability of New construction and major renovation (TREES-NC). The findings show that there are twenty two elements of three categories which are neighbourhood design, community management, and environmental condition. Moreover, only one element in neighbourhood designs different between the international and local tools. The sustainable assessment tools have existed in BMR but they are not complete in only one assessment tool. Thus, the development of new comprehensive assessment tool will be necessary in BMR; however, it should meet the specific environment and climate condition for housing estate development at BMR.

The significance of owner participation in a successful detached housing development in Malaysia: A literature review

The detached housing scheme is a unique and exclusive segment of the residential property market in Malaysia. Generally, the product is expensive and for many Malaysians who can afford them, owning a detached house is a once in a lifetime opportunity. In spite of this, most of the owners fail to fully comprehend the specific need of this type of housing scheme, increasing the risk of it being a problematic project. Unlike other types of pre-designed ‘mass housing’ schemes, the detached housing scheme may be built specifically to cater the needs and demands of its owner. Therefore, maximum owner participation is vital as the development progresses to guarantee the success of the project. In addition, due to it’s unique design the house would have to individually comply with the requirements and regulations of relevant authorities. Failure of owner to recognise this will result in delays, fines and penalties, disputes and ultimately cost overruns. These circumstances highlight the need for a model to guide the owner through the entire development process of a detached house. Therefore, this research aims to develop a model for a successful detached housing development in Malaysia through maximising owner participation during it’s various development stages. To achieve this, questionnaire surveys and case studies methods shall be employed to acquire the detached housing owners’ experiences in developing their detached houses in Malaysia. Relevant statistical tools shall be applied to analyse the responses. The results gained from this study shall be synthesised into a model of successful detached housing development for the reference of future detached housing owners in Malaysia.

Householder experiences with resource monitoring technology in sustainable homes

The use of feedback technologies, in the form of products such as Smart Meters, is increasingly seen as the means by which 'consumers' can be made aware of their patterns of resource consumption, and to then use this enhanced awareness to change their behaviour to reduce the environmental impacts of their consumption. These technologies tend to be single-resource focused (e.g. on electricity consumption only) and their functionality defined by persons other than end-users (e.g. electricity utilities). This paper presents initial findings of end-users' experiences with a multi-resource feedback technology, within the context of sustainable housing. It proposes that an understanding of user context, supply chain management and market diffusion issues are important design considerations that contribute to technology 'success'.

Gas boosted solar water heaters : Queensland case studies of installation practices in new homes

Because of the greenhouse gas emissions implications of the market dominating electric hot water systems, governments in Australia have implemented policies and programs to encourage the uptake of solar water heaters (SWHs) in the residential market as part of climate change adaptation and mitigation strategies. The cost-benefit analysis that usually accompanies all government policy and program design could be simplistically reduced to the ratio of expected greenhouse gas reductions of SWH to the cost of a SWH. The national Register of Solar Water Heaters specifies how many renewable energy certificates (RECs) are allocated to complying SWHs according to their expected performance, and hence greenhouse gas reductions, in different climates. Neither REC allocations nor rebates are tied to actual performance of systems. This paper examines the performance of instantaneous gas-boosted solar water heaters installed in new residences in a housing estate in south-east Queensland in the period 2007 – 2010. The evidence indicates systemic failures in installation practices, resulting in zero solar performance or dramatic underperformance (estimated average 43% solar contribution). The paper will detail the faults identified, and how these faults were eventually diagnosed and corrected. The impacts of these system failures on end-use consumers are discussed before concluding with a brief overview of areas where further research is required in order to more fully understand whole of supply chain implications.

Air ion concentrations in various urban outdoor environments

Atmospheric ions are produced by many natural and anthropogenic sources and their concentrations vary widely between different environments. There is very little information on their concentrations in different types of urban environments, how they compare across these environments and their dominant sources. In this study, we measured airborne concentrations of small ions, particles and net particle charge at 32 different outdoor sites in and around a major city in Australia and identified the main ion sources. Sites were classified into seven groups as follows: park, woodland, city centre, residential, freeway, power lines and power substation. Generally, parks were situated away from ion sources and represented the urban background value of about 270 ions cm-3. Median concentrations at all other groups were significantly higher than in the parks. We show that motor vehicles and power transmission systems are two major ion sources in urban areas. Power lines and substations constituted strong unipolar sources, while motor vehicle exhaust constituted strong bipolar sources. The small ion concentration in urban residential areas was about 960 cm-3. At sites where ion sources were co-located with particle sources, ion concentrations were inhibited due to the ion-particle attachment process. These results improved our understanding on air ion distribution and its interaction with particles in the urban outdoor environment.