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.

Influences of luminance and accommodation stimuli on pupil size and pupil center location

PURPOSE. To investigate effects of luminance and accommodation stimuli on pupil size and pupil center location and their implications for progressive addition lens wear. METHODS. Participants were young and older adult groups (n=20, 22±2 years, age range 18-25 years; n=19, 49±4 years, 45-58 years). A wave aberrometer included a relay system to allow a 12.5°x11° background for the internal fixation target. Participants viewed the target under a matrix of conditions with luminance levels 0.01, 3.7, 120 and 6100 cd/m² and with accommodation stimuli up to 6 diopters in 2 diopter steps. Pupil sizes and their centers, relative to limbus centers, were determined from anterior eye images. RESULTS. With luminance increase, reduction in pupil size was accentuated by increase in accommodation stimulus in the young, but not in the older, group. As luminance increased, pupil center location altered. This was nasally in both groups with an average shift of approximately 0.12mm. Relative to the lowest stimulus condition, the mean of the maximum absolute pupil center shifts was 0.26±0.08mm for both groups with individual shifts up to 0.5mm, findings consistent with previous studies. There was no significant effect of accommodation on pupil center locations for either age group, or evidence that location was influenced by the combination of luminance and accommodation stimulus that resulted in any particular pupil size. CONCLUSIONS. Variations in luminance and accommodation influence pupil size, but only the former affects pupil center location significantly. Pupil center shifts are too small to be of concern in fitting progressive addition lenses.

New particle formation and growth at a remote, sub-tropical coastal location

A month-long intensive measurement campaign was conducted in March/April 2007 at Agnes Water, a remote coastal site just south of the Great Barrier Reef on the east coast of Australia. Particle and ion size distributions were continuously measured during the campaign. Coastal nucleation events were observed in clean, marine air masses coming from the south-east on 65% of the days. The events usually began at ~10:00 local time and lasted for 1-4 hrs. They were characterised by the appearance of a nucleation mode with a peak diameter of ~10 nm. The freshly nucleated particles grew within 1-4 hrs up to sizes of 20-50 nm. The events occurred when solar intensity was high (~1000 W m-2) and RH was low (~60%). Interestingly, the events were not related to tide height. The volatile and hygroscopic properties of freshly nucleated particles (17-22.5 nm), simultaneously measured with a volatility-hygroscopicity-tandem differential mobility analyser (VH-TDMA), were used to infer chemical composition. The majority of the volume of these particles was attributed to internally mixed sulphate and organic components. After ruling out coagulation as a source of significant particle growth, we conclude that the condensation of sulphate and/or organic vapours was most likely responsible for driving particle growth during the nucleation events. We cannot make any direct conclusions regarding the chemical species that participated in the initial particle nucleation. However, we suggest that nucleation may have resulted from the photo-oxidation products of unknown sulphur or organic vapours emitted from the waters of Hervey Bay, or from the formation of DMS-derived sulphate clusters over the open ocean that were activated to observable particles by condensable vapours emitted from the nutrient rich waters around Fraser Island or Hervey Bay. Furthermore, a unique and particularly strong nucleation event was observed during northerly wind. The event began early one morning (08:00) and lasted almost the entire day resulting in the production of a large number of ~80 nm particles (average modal concentration during the event was 3200 cm-3). The Great Barrier Reef was the most likely source of precursor vapours responsible for this event.

Investigating erythemal UV exposure and vitamin D production in the urban canyon

Exposure to ultraviolet radiation (UV) results in both damaging and beneficial health outcomes. Excessive UV exposure has been linked to many skin and eye problems, but moderate exposure induces vitamin D production. It has been reported that humans receive 90-95% of their vitamin D from production that starts after UV exposure. Although it is possible to acquire vitamin D through dietary supplementation, the average person receives very little in this manner. Therefore, since most people acquire their vitamin D from synthesis after exposure to UV from sunlight, it is very important to understand the different environments in which people encounter UV. This project measured UV radiation and in-vitro vitamin D production in the urban canyon and at a nearby suburban location. The urban canyon is an environment consisting of tall buildings and tropospheric air pollution, which have an attenuating effect on UV. Typically, UV measurements are collected in areas outside the urban canyon, meaning that at times studies and public recommendations do not accurately represent the amount of UV reaching street-level in highly urbanized areas. Understanding of UV exposure in urban canyons becomes increasingly important as the number of people working and living in large cities steadily increases worldwide. This study was conducted in the central business district (CBD) of Brisbane, Australia, which models the urban canyons of large cities around the world in that it boasts a great number of tall buildings, including many skyscrapers, meaning that most areas only see a small amount of direct sunlight each day. During the winter of 2007 measurements of UV radiation and in-vitro vitamin D production were collected in the CBD and at a suburban site approximately 2.5km outside the CBD. Air pollution data was obtained from a central CBD measurement site. Data analysis showed that urban canyon measurements of both UV radiation and in-vitro vitamin D production were significantly lower than those collected at the suburban site. These results will aid both future researchers and policy makers in better understanding human UV exposure in Brisbane’s CBD and other urban canyons around the world.

Negotiating social and moral order in internet relay chat

Although internet chat is a significant aspect of many internet users’ lives, the manner in which participants in quasi-synchronous chat situations orient to issues of social and moral order remains to be studied in depth. The research presented here is therefore at the forefront of a continually developing area of study. This work contributes new insights into how members construct and make accountable the social and moral orders of an adult-oriented Internet Relay Chat (IRC) channel by addressing three questions: (1) What conversational resources do participants use in addressing matters of social and moral order? (2) How are these conversational resources deployed within IRC interaction? and (3) What interactional work is locally accomplished through use of these resources? A survey of the literature reveals considerable research in the field of computer-mediated communication, exploring both asynchronous and quasi-synchronous discussion forums. The research discussed represents a range of communication interests including group and collaborative interaction, the linguistic construction of social identity, and the linguistic features of online interaction. It is suggested that the present research differs from previous studies in three ways: (1) it focuses on the interaction itself, rather than the ways in which the medium affects the interaction; (2) it offers turn-by-turn analysis of interaction in situ; and (3) it discusses membership categories only insofar as they are shown to be relevant by participants through their talk. Through consideration of the literature, the present study is firmly situated within the broader computer-mediated communication field. Ethnomethodology, conversation analysis and membership categorization analysis were adopted as appropriate methodological approaches to explore the research focus on interaction in situ, and in particular to investigate the ways in which participants negotiate and co-construct social and moral orders in the course of their interaction. IRC logs collected from one chat room were analysed using a two-pass method, based on a modification of the approaches proposed by Pomerantz and Fehr (1997) and ten Have (1999). From this detailed examination of the data corpus three interaction topics are identified by means of which participants clearly orient to issues of social and moral order: challenges to rule violations, ‘trolling’ for cybersex, and experiences regarding the 9/11 attacks. Instances of these interactional topics are subjected to fine-grained analysis, to demonstrate the ways in which participants draw upon various interactional resources in their negotiation and construction of channel social and moral orders. While these analytical topics stand alone in individual focus, together they illustrate different instances in which participants’ talk serves to negotiate social and moral orders or collaboratively construct new orders. Building on the work of Vallis (2001), Chapter 5 illustrates three ways that rule violation is initiated as a channel discussion topic: (1) through a visible violation in open channel, (2) through an official warning or sanction by a channel operator regarding the violation, and (3) through a complaint or announcement of a rule violation by a non-channel operator participant. Once the topic has been initiated, it is shown to become available as a topic for others, including the perceived violator. The fine-grained analysis of challenges to rule violations ultimately demonstrates that channel participants orient to the rules as a resource in developing categorizations of both the rule violation and violator. These categorizations are contextual in that they are locally based and understood within specific contexts and practices. Thus, it is shown that compliance with rules and an orientation to rule violations as inappropriate within the social and moral orders of the channel serves two purposes: (1) to orient the speaker as a group member, and (2) to reinforce the social and moral orders of the group. Chapter 6 explores a particular type of rule violation, solicitations for ‘cybersex’ known in IRC parlance as ‘trolling’. In responding to trolling violations participants are demonstrated to use affiliative and aggressive humour, in particular irony, sarcasm and insults. These conversational resources perform solidarity building within the group, positioning non-Troll respondents as compliant group members. This solidarity work is shown to have three outcomes: (1) consensus building, (2) collaborative construction of group membership, and (3) the continued construction and negotiation of existing social and moral orders. Chapter 7, the final data analysis chapter, offers insight into how participants, in discussing the events of 9/11 on the actual day, collaboratively constructed new social and moral orders, while orienting to issues of appropriate and reasonable emotional responses. This analysis demonstrates how participants go about ‘doing being ordinary’ (Sacks, 1992b) in formulating their ‘first thoughts’ (Jefferson, 2004). Through sharing their initial impressions of the event, participants perform support work within the interaction, in essence working to normalize both the event and their initial misinterpretation of it. Normalising as a support work mechanism is also shown in relation to participants constructing the ‘quiet’ following the event as unusual. Normalising is accomplished by reference to the indexical ‘it’ and location formulations, which participants use both to negotiate who can claim to experience the ‘unnatural quiet’ and to identify the extent of the quiet. Through their talk participants upgrade the quiet from something legitimately experienced by one person in a particular place to something that could be experienced ‘anywhere’, moving the phenomenon from local to global provenance. With its methodological design and detailed analysis and findings, this research contributes to existing knowledge in four ways. First, it shows how rules are used by participants as a resource in negotiating and constructing social and moral orders. Second, it demonstrates that irony, sarcasm and insults are three devices of humour which can be used to perform solidarity work and reinforce existing social and moral orders. Third, it demonstrates how new social and moral orders are collaboratively constructed in relation to extraordinary events, which serve to frame the event and evoke reasonable responses for participants. And last, the detailed analysis and findings further support the use of conversation analysis and membership categorization as valuable methods for approaching quasi-synchronous computer-mediated communication.

Source location of acoustic emission waves for structural health monitoring of bridges

The process of structural health monitoring (SHM) involves monitoring a structure over a period of time using appropriate sensors, extracting damage sensitive features from the measurements made by the sensors and analysing these features to determine the current state of the structure. Various techniques are available for structural health monitoring of structures and acoustic emission (AE) is one technique that is finding an increasing use. Acoustic emission waves are the stress waves generated by the mechanical deformation of materials. AE waves produced inside a structure can be recorded by means of sensors attached on the surface. Analysis of these recorded signals can locate and assess the extent of damage. This paper describes preliminary studies on the application of AE technique for health monitoring of bridge structures. Crack initiation or structural damage will result in wave propagation in solid and this can take place in various forms. Propagation of these waves is likely to be affected by the dimensions, surface properties and shape of the specimen. This, in turn, will affect source localization. Various laboratory test results will be presented on source localization, using pencil lead break tests. The results from the tests can be expected to aid in enhancement of knowledge of acoustic emission process and development of effective bridge structure diagnostics system.

An Improved Synthetic Route to the Potent Angiogenesis Inhibitor Benzyl Manα(1→3)-Manα(1→3)-Manα(1→3)-Manα(1→2)-Man Hexadecasulfate

An improved synthetic route to α(1→3)/α(1→2)-linked mannooligosaccharides has been developed and applied to a more efficient preparation of the potent anti-angiogenic sulfated pentasaccharide, benzyl Manα(1→3)-Manα(1→3)-Manα(1→3)-Manα(1→2)-Man hexadecasulfate, using only two monosaccharide building blocks. Of particular note are improvements in the preparation of both building blocks and a simpler, final deprotection strategy. The route also provides common intermediates for the introduction of aglycones other than benzyl, either at the building block stage or after oligosaccharide assembly. The anti-angiogenic activity of the synthesized target compound was confirmed via the rat aortic assay.

Unusual hydrate stabilization in the two-dimensional layered structure of quinacrinium bis(2-carboxy-4,5-dichlorobenzoate) tetrahydrate, a proton-transfer compound of the drug quinacrine

The crystal structure of the hydrated proton-transfer compound of the drug quinacrine [rac-N'-(6-chloro-2-methoxyacridin-9-yl)-N,N-diethylpentane-1,4-diamine] with 4,5-dichlorophthalic acid, C23H32ClN3O2+ . 2(C8H3Cl2O4-).4H2O (I), has been determined at 200 K. The four labile water molecules of solvation form discrete ...O--H...O--H... hydrogen-bonded chains parallel to the quinacrine side chain, the two N--H groups of which act as hydrogen-bond donors for two of the water acceptor molecules. The other water molecules, as well as the acridinium H atom, also form hydrogen bonds with the two anion species and extend the structure into two-dimensional sheets. Between these sheets there are also weak cation--anion and anion--anion pi-pi aromatic ring interactions. This structure represents only the third example of a simple quinacrine derivative for which structural data are available but differs from the other two in that it is unstable in the X-ray beam due to efflorescence, probably associated with the destruction of the unusual four-membered water chain structures.

Is the Marlboro man the only alternative? The role of gender identity and self-construal salience in evaluations of male models

This research examines how men react to male models in print advertisements. In two experiments, we show that the gender identity of men influences their responses to advertisements featuring a masculine, feminine, or androgynous male model. In addition, we explore the extent to which men feel they will be classified by others as similar to the model as a mechanism for these effects. Specifically, masculine men respond most favorably to masculine models and are negative toward feminine models. In contrast, feminine men prefer feminine models when their private self is salient. Yet in a collective context, they prefer masculine models.These experiments shed light on how gender identity and self-construal influence male evaluations and illustrate the social pressure on men to endorse traditional masculine portrayals. We also present implications for advertising practice.

Bearing-only SLAM : a vision-based navigation system for autonomous robots

To navigate successfully in a previously unexplored environment, a mobile robot must be able to estimate the spatial relationships of the objects of interest accurately. A Simultaneous Localization and Mapping (SLAM) sys- tem employs its sensors to build incrementally a map of its surroundings and to localize itself in the map simultaneously. The aim of this research project is to develop a SLAM system suitable for self propelled household lawnmowers. The proposed bearing-only SLAM system requires only an omnidirec- tional camera and some inexpensive landmarks. The main advantage of an omnidirectional camera is the panoramic view of all the landmarks in the scene. Placing landmarks in a lawn field to define the working domain is much easier and more flexible than installing the perimeter wire required by existing autonomous lawnmowers. The common approach of existing bearing-only SLAM methods relies on a motion model for predicting the robot’s pose and a sensor model for updating the pose. In the motion model, the error on the estimates of object positions is cumulated due mainly to the wheel slippage. Quantifying accu- rately the uncertainty of object positions is a fundamental requirement. In bearing-only SLAM, the Probability Density Function (PDF) of landmark position should be uniform along the observed bearing. Existing methods that approximate the PDF with a Gaussian estimation do not satisfy this uniformity requirement. This thesis introduces both geometric and proba- bilistic methods to address the above problems. The main novel contribu- tions of this thesis are: 1. A bearing-only SLAM method not requiring odometry. The proposed method relies solely on the sensor model (landmark bearings only) without relying on the motion model (odometry). The uncertainty of the estimated landmark positions depends on the vision error only, instead of the combination of both odometry and vision errors. 2. The transformation of the spatial uncertainty of objects. This thesis introduces a novel method for translating the spatial un- certainty of objects estimated from a moving frame attached to the robot into the global frame attached to the static landmarks in the environment. 3. The characterization of an improved PDF for representing landmark position in bearing-only SLAM. The proposed PDF is expressed in polar coordinates, and the marginal probability on range is constrained to be uniform. Compared to the PDF estimated from a mixture of Gaussians, the PDF developed here has far fewer parameters and can be easily adopted in a probabilistic framework, such as a particle filtering system. The main advantages of our proposed bearing-only SLAM system are its lower production cost and flexibility of use. The proposed system can be adopted in other domestic robots as well, such as vacuum cleaners or robotic toys when terrain is essentially 2D.

Real estate agency practice and profitability : an analysis of house sales and agency profitability in Sydney

Large cities provide a broad range of residential property types, as well as a range of socio-economic locations. This results in a significant variation in residential property prices across both the city itself and the individual suburbs. The only constant across such a diverse range of residential property is the need for the majority of residential property owners to employ the services of a real estate agent to sell their property or to purchase a residential property. This paper will analyse the Sydney residential property market over the period 1994 to 2002 to determine the change in real estate offices numbers over the period, the profitability of real estate agency offices based on the residential house price performance of houses and units in these specific locations and the extent of changing residential house prices on agency profitability. Suburbs have been selected to provide a full range of housing types, socio-economic areas, older established and developing residential suburbs and location from the

Mapping personal trip OD from probe data

The paper analyses the expected value of OD volumes from probe with fixed error, error that is proportional to zone size and inversely proportional to zone size. To add realism to the analysis, real trip ODs in the Tokyo Metropolitan Region are synthesised. The results show that for small zone coding with average radius of 1.1km, and fixed measurement error of 100m, an accuracy of 70% can be expected. The equivalent accuracy for medium zone coding with average radius of 5km would translate into a fixed error of approximately 300m. As expected small zone coding is more sensitive than medium zone coding as the chances of the probe error envelope falling into adjacent zones are higher. For the same error radii, error proportional to zone size would deliver higher level of accuracy. As over half (54.8%) of the trip ends start or end at zone with equivalent radius of ≤ 1.2 km and only 13% of trips ends occurred at zones with equivalent radius ≥2.5km, measurement error that is proportional to zone size such as mobile phone would deliver higher level of accuracy. The synthesis of real OD with different probe error characteristics have shown that expected value of >85% is difficult to achieve for small zone coding with average radius of 1.1km. For most transport applications, OD matrix at medium zone coding is sufficient for transport management. From this study it can be drawn that GPS with error range between 2 and 5m, and at medium zone coding (average radius of 5km) would provide OD estimates greater than 90% of the expected value. However, for a typical mobile phone operating error range at medium zone coding the expected value would be lower than 85%. This paper assumes transmission of one origin and one destination positions from the probe. However, if multiple positions within the origin and destination zones are transmitted, map matching to transport network could be performed and it would greatly improve the accuracy of the probe data.

Robot navigation in sensor space

This thesis investigates the problem of robot navigation using only landmark bearings. The proposed system allows a robot to move to a ground target location specified by the sensor values observed at this ground target posi- tion. The control actions are computed based on the difference between the current landmark bearings and the target landmark bearings. No Cartesian coordinates with respect to the ground are computed by the control system. The robot navigates using solely information from the bearing sensor space. Most existing robot navigation systems require a ground frame (2D Cartesian coordinate system) in order to navigate from a ground point A to a ground point B. The commonly used sensors such as laser range scanner, sonar, infrared, and vision do not directly provide the 2D ground coordi- nates of the robot. The existing systems use the sensor measurements to localise the robot with respect to a map, a set of 2D coordinates of the objects of interest. It is more natural to navigate between the points in the sensor space corresponding to A and B without requiring the Cartesian map and the localisation process. Research on animals has revealed how insects are able to exploit very limited computational and memory resources to successfully navigate to a desired destination without computing Cartesian positions. For example, a honeybee balances the left and right optical flows to navigate in a nar- row corridor. Unlike many other ants, Cataglyphis bicolor does not secrete pheromone trails in order to find its way home but instead uses the sun as a compass to keep track of its home direction vector. The home vector can be inaccurate, so the ant also uses landmark recognition. More precisely, it takes snapshots and compass headings of some landmarks. To return home, the ant tries to line up the landmarks exactly as they were before it started wandering. This thesis introduces a navigation method based on reflex actions in sensor space. The sensor vector is made of the bearings of some landmarks, and the reflex action is a gradient descent with respect to the distance in sensor space between the current sensor vector and the target sensor vec- tor. Our theoretical analysis shows that except for some fully characterized pathological cases, any point is reachable from any other point by reflex action in the bearing sensor space provided the environment contains three landmarks and is free of obstacles. The trajectories of a robot using reflex navigation, like other image- based visual control strategies, do not correspond necessarily to the shortest paths on the ground, because the sensor error is minimized, not the moving distance on the ground. However, we show that the use of a sequence of waypoints in sensor space can address this problem. In order to identify relevant waypoints, we train a Self Organising Map (SOM) from a set of observations uniformly distributed with respect to the ground. This SOM provides a sense of location to the robot, and allows a form of path planning in sensor space. The navigation proposed system is analysed theoretically, and evaluated both in simulation and with experiments on a real robot.