The effect of implementing a modified early warning scoring (MEWS) system on the adequacy of vital sign documentation

Introduction and objectives Early recognition of deteriorating patients results in better patient outcomes. Modified early warning scores (MEWS) attempt to identify deteriorating patients early so timely interventions can occur thus reducing serious adverse events. We compared frequencies of vital sign recording 24 h post-ICU discharge and 24 h preceding unplanned ICU admission before and after a new observation chart using MEWS and an associated educational programme was implemented into an Australian Tertiary referral hospital in Brisbane. Design Prospective before-and-after intervention study, using a convenience sample of ICU patients who have been discharged to the hospital wards, and in patients with an unplanned ICU admission, during November 2009 (before implementation; n = 69) and February 2010 (after implementation; n = 70). Main outcome measures Any change in a full set or individual vital sign frequency before-and-after the new MEWS observation chart and associated education programme was implemented. A full set of vital signs included Blood pressure (BP), heart rate (HR), temperature (T°), oxygen saturation (SaO2) respiratory rate (RR) and urine output (UO). Results After the MEWS observation chart implementation, we identified a statistically significant increase (210%) in overall frequency of full vital sign set documentation during the first 24 h post-ICU discharge (95% CI 148, 288%, p value <0.001). Frequency of all individual vital sign recordings increased after the MEWS observation chart was implemented. In particular, T° recordings increased by 26% (95% CI 8, 46%, p value = 0.003). An increased frequency of full vital sign set recordings for unplanned ICU admissions were found (44%, 95% CI 2, 102%, p value = 0.035). The only statistically significant improvement in individual vital sign recordings was urine output, demonstrating a 27% increase (95% CI 3, 57%, p value = 0.029). Conclusions The implementation of a new MEWS observation chart plus a supporting educational programme was associated with statistically significant increases in frequency of combined and individual vital sign set recordings during the first 24 h post-ICU discharge. There were no significant changes to frequency of individual vital sign recordings in unplanned admissions to ICU after the MEWS observation chart was implemented, except for urine output. Overall increases in the frequency of full vital sign sets were seen.

Delineating the practice profile of advanced practice nursing : a cross-sectional survey using the modified strong model of advanced practice

AIMS: To test a model that delineates advanced practice nursing from the practice profile of other nursing roles and titles. BACKGROUND: There is extensive literature on advanced practice reporting the importance of this level of nursing to contemporary health service and patient outcomes. Literature also reports confusion and ambiguity associated with advanced practice nursing. Several countries have regulation and delineation for the nurse practitioner, but there is less clarity in definition and service focus of other advanced practice nursing roles. DESIGN: A statewide survey. METHODS: Using the modified Strong Model of Advanced Practice Role Delineation tool, a survey was conducted in 2009 with a random sample of registered nurses/midwives from government facilities in Queensland, Australia. Analysis of variance compared total and subscale scores across groups according to grade. Linear, stepwise multiple regression analysis examined factors influencing advanced practice nursing activities across all domains. RESULTS: There were important differences according to grade in mean scores for total activities in all domains of advanced practice nursing. Nurses working in advanced practice roles (excluding nurse practitioners) performed more activities across most advanced practice domains. Regression analysis indicated that working in clinical advanced practice nursing roles with higher levels of education were strong predictors of advanced practice activities overall. CONCLUSION: Essential and appropriate use of advanced practice nurses requires clarity in defining roles and practice levels. This research delineated nursing work according to grade and level of practice, further validating the tool for the Queensland context and providing operational information for assigning innovative nursing service.

Value added products from modified kaolins : new chemical routes to new markets

Chemical treatments of kaolins to produce nanocrystalline or "X-ray amorphous", stable aluminosilicates with variable - but reproducible - types of micro- and meso-porosity have been developed. These materials show cation exchange capacities and surface area values significantly higher (ranging from 10x to 100x) than kaolin and show good acid resistance to pH~3.0. The combination of these properties offers strong potential for many new applications of kaolin-derived materials in large worldwide markets such as environmental remediation and catalysis. Kaolin amorphous derivative (KAD) is well-suited to removal of many toxic metals down to ppb range from acid mine drainage. Engineering development trials of the KAD manufacturing process and the utilisation of KAD in polluted waters such as acid mine drainage indicates that scale-up from bench-scale is not a barrier to market entry.

Were intercalated komatiites and dacites at the Black Swan nickel sulphide mine, Yilgarn Craton, Western Australia, emplaced as extrusive lavas or intrusive bodies? The significance of breccia textures and contact relationships

Intercalated Archean komatiites and dacites sit above a thick footwall dacite unit in the host rock succession at the Black Swan Nickel Mine, north of Kalgoorlie in the Yilgarn Craton, Western Australia. Both lithofacies occur in units that vary in scale from laterally extensive at the scale of the mine lease to localized, thin, irregular bodies, from > 100 m thick to only centimetres thick. Some dacites are only slightly altered and deformed, and are interpreted to post-date major deformation and alteration (late porphyries). However, the majority of the dacites display evidence of deformation, especially at contacts, and metamorphism, varying from silicification and chlorite alteration at contacts to pervasive low grade regional metamorphic alteration represented by common assemblages of chlorite, sericite and albite. Texturally, the dacites vary from entirely massive and coherent to partially brecciated to totally brecciated. Strangely, some dacites are coherent at the margins and brecciated internally. Breccia textures vary from cryptically defined, to blocky, closely packed, in situ jig-saw fit textures with secondary minerals in fractures between clasts, to more apparent matrix rich textures with round clast forms, giving apparent conglomerate textures. Some clast zones have multi-coloured clasts, giving the impression of varied provenance. Strangely however, all these textural variants have gradational relationships with each other, and no bedding or depositional structures are present. This indicates that all textures have an in situ origin. The komatiites are generally altered and pervasively carbonate veined. Preservation of original textures is patchy and local, but includes coarse adcumulate, mesocumulate, orthocumulate, crescumulate-harrisite and occasionally spinifex textures. Where original contacts between komatiites and dacites are preserved intact (i.e. not sheared or overprinted by alteration), the komatiites have chilled margins, whereas the dacites do not. The margins of the dacites are commonly silicified, and inclusions of dacite occur in komatiite, even at the top contacts of komatiite units, but komatiite clasts do not occur in the dacites. The komatiites therefore were emplaced as sills into the dacites, and the intercalated relationships are interpreted as intrusive. The brecciation and alteration in the dacites are interpreted as being largely due to hydraulic fracturing and alteration induced by contact metamorphic effects and hydrothermal alteration deriving from the intrusion of komatiites into the felsic pile. The absence of autobreccia and hyaloclastite textures in the dacites suggest that they were emplaced as an earlier intrusive (sill?) complex at a high level in the crust.

Modified kaolins

A process for the preparation of a modified kaolin from a kaolin group mineral which includes expansion and contraction of layers of the kaolin group mineral. The layers comprising one Si-tetrahedral sheet and one Al-octahedral sheet. The expansion and contraction may be initiated by initial intercalation of a reagent which can penetrate kaolin layers to reach an interlayer region there between to form an intercalate. Subsequently, the intercalation may be followed by de-intercalation which involves the removal of the reagent. By the above process, there is provided crystalline modified kaolins having the following properties: (i) an increased interlayer space compared to corresponding kaolin group minerals; (ii) an increased susceptibility to intercalation by cations, anions or salts compared to corresponding kaolin group minerals; and (iii) an increased exfoliated morphology compared to corresponding kaolin group minerals.

Advanced practice nursing role development : factor analysis of a modified role delineation tool

Aim his study reports the use of exploratory factor analysis to determine construct validity of a modified advanced practice role delineation tool. Background Little research exists on specific activities and domains of practice within advanced practice nursing roles, making it difficult to define service parameters of this level of nursing practice. A valid and reliable tool would assist those responsible for employing or deploying advanced practice nurses by identifying and defining their service profile. This is the third paper from a multi-phase Australian study aimed at assigning advanced practice roles. Methods A postal survey was conducted of a random sample of state government employed Registered nurses and midwives, across various levels and grades of practice in the state of Queensland, Australia, using the modified Advanced Practice Role Delineation tool. Exploratory factor analysis, using principal axis factoring was undertaken to examine factors in the modified tool. Cronbach’s alpha coefficient determined reliability of the overall scale and identified factors. Results There were 658 responses (42% response rate). The five factors found with loadings of ≥.400 for 40 of the 41 APN activities were similar to the five domains in the Strong model. Cronbach’s alpha coefficient was .94 overall and for the factors ranged from 0.83 to 0.95. Conclusion Exploratory factor analysis of the modified tool supports validity of the five domains of the original tool. Further investigation will identify use of the tool in a broader healthcare environment.

Non-Newtonian natural convection flow along an isothermal horizontal circular cylinder using modified power-law model

Laminar two-dimensional natural convection boundary-layer flow of non-Newtonian fluids along an isothermal horizontal circular cylinder has been studied using a modified power-law viscosity model. In this model, there are no unrealistic limits of zero or infinite viscosity. Therefore, the boundary-layer equations can be solved numerically by using marching order implicit finite difference method with double sweep technique. Numerical results are presented for the case of shear-thinning as well as shear thickening fluids in terms of the fluid velocity and temperature distributions, shear stresses and rate of heat transfer in terms of the local skin-friction and local Nusselt number respectively.

Increasing NH4+ retention efficiency of sandy soils by adding a modified kaolin material: Mesolite

Water and ammonium retention by sandy soils may be low and result in leaching of applied fertiliser. To increase water and nutrient retention, zeolite is sometimes applied as a soil ameliorant for high value land uses including turf and horticulture. We have used a new modified kaolin material (MesoLite) as a soil amendment to test the efficiency of NH4+ retention and compared the results with natural zeolite. MesoLite is made by caustic reaction of kaolin at temperature between 80-95°C; although it has a moderate surface area, its cation exchange capacity is very high;(SA=13m2/g,CEC=500meq/100g). A 13cm tall sand column filled with ~450g of sandy soil homogeneously mixed with 1, 2, 4, and 8g of MesoLite or natural zeolite per 1kg of soil was prepared. After saturation with local bore water, concentrated ammonium sulfate solution was injected at the base. Then, bore water was passed from bottom to top through the column at amounts up to 6 pore volumes and at a constant flow rate of 10ml/min using a peristaltic pump. Concentrations of leached NH4+ were determined using an AutoAnalyser. The concentration of NH4+ leached from the column with 0.4% MesoLite was greatly (90%) reduced relative to unamended soil. Under these conditions NH4+ retention by the soil-MesoLite mixture was 11.5 times more efficient than the equivalent soil-natural zeolite mixture. Glasshouse experiments conducted in a separate study show that NH4+ adsorbed by MesoLite is available to plants.

Charge carrier exchange at chemically modified graphene edges: A density functional theory study

Heteroatom doping on the edge of graphene may serve as an effective way to tune chemical activity of carbon-based electrodes with respect to charge carrier transfer in an aqueous environment. In a step towards developing mechanistic understanding of this phenomenon, we explore herein mechanisms of proton transfer from aqueous solution to pristine and doped graphene edges utilizing density functional theory. Atomic B-, N-, and O- doped edges as well as the native graphene are examined, displaying varying proton affinities and effective interaction ranges with the H3O+ charge carrier. Our study shows that the doped edges characterized by more dispersive orbitals, namely boron and nitrogen, demonstrate more energetically favourable charge carrier exchange compared with oxygen, which features more localized orbitals. Extended calculations are carried out to examine proton transfer from the hydronium ion in the presence of explicit water, with results indicating that the basic mechanistic features of the simpler model are unchanged.

Chemically modified ribbon edge stimulated H2 dissociation: A first-principles computational study

First-principles computational studies indicate that (B, N, or O)-doped graphene ribbon edges can substantially reduce the energy barrier for H2 dissociative adsorption. The low barrier is competitive with many widely used metal or metal oxide catalysts. This suggests that suitably functionalized graphene architectures are promising metal-free alternatives for low-cost catalytic processes.

Characterisation of SiO2-supported nickel catalysts for carbon dioxide reforming of methane

The CO2-methane reformation reaction over Ni/SiO2 catalysts has been extensively studied using a range of temperature-programmed techniques and characterisation of the catalysts by thermogravimetry (TG), X-ray diffraction (XRD) and electron microscopy (TEM). The results indicate a strong correlation between the microstructure of the catalyst and its performance. The role of both CO2 and CH4 in the reaction has been investigated and the role of methyl radicals in the reaction mechanism highlighted. A reaction mechanism involving dissociatively adsorbed CO2 and methyl radicals has been proposed.

Thermal stability and hot-stage Raman spectroscopic study of Ca-montmorillonite modified with different surfactants : a comparative study

Three long chain cationic surfactants were intercalated into Ca-montmorillonite through ion exchangeand the obtained organoclays were characterized by X-ray diffraction (XRD), high resolution thermo-gravimetric analysis (TG) and Raman spectroscopy. The intercalation of surfactants not only changes thesurface properties of clay from hydrophilic to hydrophobic but also greatly increases the basal spacing ofthe interlayers based on XRD analysis. The thermal stability of organoclays intercalated with three sur-factants (TTAB, DTAB and CTAB) and the different arrangements of the surfactant molecules intercalatedinto Ca-montmorillonite were determined by TG-DTG analysis. A Raman spectroscopic study on the Ca-montmorillonite modified by three surfactants prepared at different concentrations provided the detailedconformational ordering of different intercalated long-chain surfactants under different conditions. Thewavenumber of the antisymmetric stretching mode is more sensitive than that of the symmetric stretch-ing mode to the mobility of the tail of the amine chain. At room temperature, the conformational orderingis more easily affected by the packing density in the lateral model. With the increase of the temperature,the positions of both the antisymmetric and symmetric stretching bands shift to higher wavenumbers,which indicates a decrease of conformational ordering. This study offers new insights into the struc-ture and properties of Ca-montmorillonite modified with different long chain surfactants. Moreover, theexperimental results confirm the potential applications of organic Ca-montmorillonites for the removalof organic impurities from aqueous media.