Setting hospital infection control policy : a decision-making framework incorporating health economics and healthcare epidemiology

Background: Reducing rates of healthcare acquired infection has been identified by the Australian Commission on Safety and Quality in Health Care as a national priority. One of the goals is the prevention of central venous catheter-related bloodstream infection (CR-BSI). At least 3,500 cases of CR-BSI occur annually in Australian hospitals, resulting in unnecessary deaths and costs to the healthcare system between $25.7 and $95.3 million. Two approaches to preventing these infections have been proposed: use of antimicrobial catheters (A-CVCs); or a catheter care and management ‘bundle’. Given finite healthcare budgets, decisions about the optimal infection control policy require consideration of the effectiveness and value for money of each approach. Objectives: The aim of this research is to use a rational economic framework to inform efficient infection control policy relating to the prevention of CR-BSI in the intensive care unit. It addresses three questions relating to decision-making in this area: 1. Is additional investment in activities aimed at preventing CR-BSI an efficient use of healthcare resources? 2. What is the optimal infection control strategy from amongst the two major approaches that have been proposed to prevent CR-BSI? 3. What uncertainty is there in this decision and can a research agenda to improve decision-making in this area be identified? Methods: A decision analytic model-based economic evaluation was undertaken to identify an efficient approach to preventing CR-BSI in Queensland Health intensive care units. A Markov model was developed in conjunction with a panel of clinical experts which described the epidemiology and prognosis of CR-BSI. The model was parameterised using data systematically identified from the published literature and extracted from routine databases. The quality of data used in the model and its validity to clinical experts and sensitivity to modelling assumptions was assessed. Two separate economic evaluations were conducted. The first evaluation compared all commercially available A-CVCs alongside uncoated catheters to identify which was cost-effective for routine use. The uncertainty in this decision was estimated along with the value of collecting further information to inform the decision. The second evaluation compared the use of A-CVCs to a catheter care bundle. We were unable to estimate the cost of the bundle because it is unclear what the full resource requirements are for its implementation, and what the value of these would be in an Australian context. As such we undertook a threshold analysis to identify the cost and effectiveness thresholds at which a hypothetical bundle would dominate the use of A-CVCs under various clinical scenarios. Results: In the first evaluation of A-CVCs, the findings from the baseline analysis, in which uncertainty is not considered, show that the use of any of the four A-CVCs will result in health gains accompanied by cost-savings. The MR catheters dominate the baseline analysis generating 1.64 QALYs and cost-savings of $130,289 per 1.000 catheters. With uncertainty, and based on current information, the MR catheters remain the optimal decision and return the highest average net monetary benefits ($948 per catheter) relative to all other catheter types. This conclusion was robust to all scenarios tested, however, the probability of error in this conclusion is high, 62% in the baseline scenario. Using a value of $40,000 per QALY, the expected value of perfect information associated with this decision is $7.3 million. An analysis of the expected value of perfect information for individual parameters suggests that it may be worthwhile for future research to focus on providing better estimates of the mortality attributable to CR-BSI and the effectiveness of both SPC and CH/SSD (int/ext) catheters. In the second evaluation of the catheter care bundle relative to A-CVCs, the results which do not consider uncertainty indicate that a bundle must achieve a relative risk of CR-BSI of at least 0.45 to be cost-effective relative to MR catheters. If the bundle can reduce rates of infection from 2.5% to effectively zero, it is cost-effective relative to MR catheters if national implementation costs are less than $2.6 million ($56,610 per ICU). If the bundle can achieve a relative risk of 0.34 (comparable to that reported in the literature) it is cost-effective, relative to MR catheters, if costs over an 18 month period are below $613,795 nationally ($13,343 per ICU). Once uncertainty in the decision is considered, the cost threshold for the bundle increases to $2.2 million. Therefore, if each of the 46 Level III ICUs could implement an 18 month catheter care bundle for less than $47,826 each, this approach would be cost effective relative to A-CVCs. However, the uncertainty is substantial and the probability of error in concluding that the bundle is the cost-effective approach at a cost of $2.2 million is 89%. Conclusions: This work highlights that infection control to prevent CR-BSI is an efficient use of healthcare resources in the Australian context. If there is no further investment in infection control, an opportunity cost is incurred, which is the potential for a more efficient healthcare system. Minocycline/rifampicin catheters are the optimal choice of antimicrobial catheter for routine use in Australian Level III ICUs, however, if a catheter care bundle implemented in Australia was as effective as those used in the large studies in the United States it would be preferred over the catheters if it was able to be implemented for less than $47,826 per Level III ICU. Uncertainty is very high in this decision and arises from multiple sources. There are likely greater costs to this uncertainty for A-CVCs, which may carry hidden costs, than there are for a catheter care bundle, which is more likely to provide indirect benefits to clinical practice and patient safety. Research into the mortality attributable to CR-BSI, the effectiveness of SPC and CH/SSD (int/ext) catheters and the cost and effectiveness of a catheter care bundle in Australia should be prioritised to reduce uncertainty in this decision. This thesis provides the economic evidence to inform one area of infection control, but there are many other infection control decisions for which information about the cost-effectiveness of competing interventions does not exist. This work highlights some of the challenges and benefits to generating and using economic evidence for infection control decision-making and provides support for commissioning more research into the cost-effectiveness of infection control.

Open standards-based system integration for asset management decision support

Over the last decade, system integration has grown in popularity as it allows organisations to streamline business processes. Traditionally, system integration has been conducted through point-to-point solutions – as a new integration scenario requirement arises, a custom solution is built between the relevant systems. Bus-based solutions are now preferred, whereby all systems communicate via an intermediary system such as an enterprise service bus, using a common data exchange model. This research investigates the use of a common data exchange model based on open standards, specifically MIMOSA OSA-EAI, for asset management system integration. A case study is conducted that involves the integration of processes between a SCADA, maintenance decision support and work management system. A diverse number of software platforms are employed in developing the final solution, all tied together through MIMOSA OSA-EAI-based XML web services. The lessons learned from the exercise are presented throughout the paper.

Contrasting scenarios : embracing speech recognition

The purpose of this chapter is to describe the use of caricatured contrasting scenarios (Bødker, 2000) and how they can be used to consider potential designs for disruptive technologies. The disruptive technology in this case is Automatic Speech Recognition (ASR) software in workplace settings. The particular workplace is the Magistrates Court of the Australian Capital Territory.----- Caricatured contrasting scenarios are ideally suited to exploring how ASR might be implemented in a particular setting because they allow potential implementations to be “sketched” quickly and with little effort. This sketching of potential interactions and the emphasis of both positive and negative outcomes allows the benefits and pitfalls of design decisions to become apparent.----- A brief description of the Court is given, describing the reasons for choosing the Court for this case study. The work of the Court is framed as taking place in two modes: Front of house, where the courtroom itself is, and backstage, where documents are processed and the business of the court is recorded and encoded into various systems.----- Caricatured contrasting scenarios describing the introduction of ASR to the front of house are presented and then analysed. These scenarios show that the introduction of ASR to the court would be highly problematic.----- The final section describes how ASR could be re-imagined in order to make it useful for the court. A final scenario is presented that describes how this re-imagined ASR could be integrated into both the front of house and backstage of the court in a way that could strengthen both processes.

Benefits of collaborative ICT adoption for building project management

Purpose : Effective flow of data and communication at every stage of a construction project is essential for achieving required coordination and collaboration between the project participants, leading to successful management of the projects. In present scenario, when project participants are geographically separated, adoption of information communication technology (ICT) enables such effective communication. Thus, the purpose of this paper is to focus on ICT adoption for building project management.---------- Design/methodology/approach : It is difficult to quantitatively evaluate the benefits of ICT adoption in the multiple enterprise scenario of building project management. It requires qualitative analysis based on the perceptions of the construction professionals. The paper utilizes interpretive structural modeling (ISM) technique to assess importance of perceived benefits and their driving power and dependence on other benefits.---------- Findings : The developed ISM model shows that all the categories of benefits, i.e. benefits related to projects, team management, technology, and organization are inter-related and cannot be achieved in isolation. But, organization- and technology-related benefits have high-driving power and these are “strategic benefits” for the project team organizations. Thus, organizations are required to give more attention on strategically increasing these benefits from application of ICT. Originality/value – This analysis provides a road map to managers or project management organizations to decide that if they are planning ICT adoption for achieving certain benefits then which are the other driving benefits that should be achieved prior to that and also which are the dependent benefits that would be achieved by default.

Study of ICT adoption for building project management in the Indian construction industry

Building project management requires effective coordination and collaboration between multiple project members. It can be achieved through real time communication flow between all. In present scenario, it can be achieved through adoption of Information and Communication Technologies (ICT). Construction industry primarily comprises small and medium enterprises (SMEs). Also, ICT adoption has been slow in the industry.---------- Research is required to assess the factors that affect ICT adoption at the three levels of industry, organization and people, with focus on SMEs. This paper discusses a component of the research undertaken to study these factors and issues in the context of Indian construction industry. A questionnaire survey was conducted and through quantitative data analysis the extent of adoption of formal Project Management processes, ICT adoption for these processes and factors including perception based factors affecting ICT adoption were studied. Results of data analysis includes identification of issues that require action at the three study levels.---------- The results can be generalized for other countries with due considerations, specifically for countries where the construction industry is similar to Indian construction industry in terms of working methodologies or for large countries.

Improving automatic speaker verification using SVM techniques

Automatic recognition of people is an active field of research with important forensic and security applications. In these applications, it is not always possible for the subject to be in close proximity to the system. Voice represents a human behavioural trait which can be used to recognise people in such situations. Automatic Speaker Verification (ASV) is the process of verifying a persons identity through the analysis of their speech and enables recognition of a subject at a distance over a telephone channel { wired or wireless. A significant amount of research has focussed on the application of Gaussian mixture model (GMM) techniques to speaker verification systems providing state-of-the-art performance. GMM's are a type of generative classifier trained to model the probability distribution of the features used to represent a speaker. Recently introduced to the field of ASV research is the support vector machine (SVM). An SVM is a discriminative classifier requiring examples from both positive and negative classes to train a speaker model. The SVM is based on margin maximisation whereby a hyperplane attempts to separate classes in a high dimensional space. SVMs applied to the task of speaker verification have shown high potential, particularly when used to complement current GMM-based techniques in hybrid systems. This work aims to improve the performance of ASV systems using novel and innovative SVM-based techniques. Research was divided into three main themes: session variability compensation for SVMs; unsupervised model adaptation; and impostor dataset selection. The first theme investigated the differences between the GMM and SVM domains for the modelling of session variability | an aspect crucial for robust speaker verification. Techniques developed to improve the robustness of GMMbased classification were shown to bring about similar benefits to discriminative SVM classification through their integration in the hybrid GMM mean supervector SVM classifier. Further, the domains for the modelling of session variation were contrasted to find a number of common factors, however, the SVM-domain consistently provided marginally better session variation compensation. Minimal complementary information was found between the techniques due to the similarities in how they achieved their objectives. The second theme saw the proposal of a novel model for the purpose of session variation compensation in ASV systems. Continuous progressive model adaptation attempts to improve speaker models by retraining them after exploiting all encountered test utterances during normal use of the system. The introduction of the weight-based factor analysis model provided significant performance improvements of over 60% in an unsupervised scenario. SVM-based classification was then integrated into the progressive system providing further benefits in performance over the GMM counterpart. Analysis demonstrated that SVMs also hold several beneficial characteristics to the task of unsupervised model adaptation prompting further research in the area. In pursuing the final theme, an innovative background dataset selection technique was developed. This technique selects the most appropriate subset of examples from a large and diverse set of candidate impostor observations for use as the SVM background by exploiting the SVM training process. This selection was performed on a per-observation basis so as to overcome the shortcoming of the traditional heuristic-based approach to dataset selection. Results demonstrate the approach to provide performance improvements over both the use of the complete candidate dataset and the best heuristically-selected dataset whilst being only a fraction of the size. The refined dataset was also shown to generalise well to unseen corpora and be highly applicable to the selection of impostor cohorts required in alternate techniques for speaker verification.

The increased flammability of metallic materials burning in reduced gravity

Data generated in a normal gravity environment is often used in design and risk assessment for reduced gravity applications. It has been clearly demonstrated that this is a conservative approach for non-metallic materials which have been repeatedly shown to be less flammable in a reduced gravity environment. However, recent work has demonstrated this is not true for metallic materials. This work, conducted in a newly completed drop tower observed a significant increase in both lowest burn pressure and burn rate in reduced gravity. Hence the normal gravity qualification of a metallic materials’ lowest burn pressure or burn rate for reduced-gravity or space-based systems is clearly not conservative. This paper presents a summary of this work and the results obtained for several metallic materials showing an increased flammability and burn rate for a range of oxygen pressures, and discusses the implications of this work on the fire-safety of space-based systems.

Portfolio size effect in retirement accounts : what does it imply for lifecycle asset allocation funds?

Lifecycle funds offered by retirement plan providers allocate aggressively to risky asset classes when the employee participants are young, gradually switching to more conservative asset classes as they grow older and approach retirement. This approach focuses on maximizing growth of the accumulation fund in the initial years and preserving its value in the later years. The authors simulate terminal wealth outcomes based on conventional lifecycle asset allocation rules as well as on contrarian strategies that reverse the direction of asset switching. The evidence suggests that the growth in portfolio size over time significantly impacts the asset allocation decision. Due to the portfolio size effect that is observed by the authors, the terminal value of accumulation in retirement accounts is influenced more by the asset allocation strategy adopted in later years relative to that adopted in early years. By mechanistically switching to conservative assets in the later years of a plan, lifecycle strategies sacrifice significant growth opportunity and prove counterproductive to the participant's wealth accumulation objective. The authors' conclude that this sacrifice does not seem to be compensated adequately in terms of reducing the risk of potentially adverse outcomes.

Effect of section geometry on the lateral distortional buckling of LiteSteel beams

The LiteSteel Beam (LSB) is a new hollow flange section developed by OneSteel Australian Tube Mills using their patented dual electric resistance welding and automated continuous roll-forming technologies. It has a unique geometry consisting of torsionally rigid rectangular hollow flanges and a relatively slender web. It has found increasing popularity in residential, industrial and commercial buildings as flexural members. The LSB is considerably lighter than traditional hot-rolled steel beams and provides both structural and construction efficiencies. However, the LSB flexural members are subjected to a relatively new lateral distortional buckling mode, which reduces their member moment capacities. Unlike the commonly observed lateral torsional buckling of steel beams, the lateral distortional buckling of LSBs is characterised by simultaneous lateral defection, twist and cross sectional change due to web distortion. The current design rules in AS/NZS 4600 (SA, 2005) for flexural members subject to lateral distortional buckling were found to be conservative by about 8% in the inelastic buckling region. Therefore, a new design rule was developed for LSBs subject to lateral distortional buckling based on finite element analyses of LSBs. The effect of section geometry was then considered and several geometrical parameters were used to develop an advanced set of design rules. This paper presents the details of the finite element analyses and the design curve development for hollow flange sections subject to lateral distortional buckling.

Ultimate shear strength of LiteSteel beams

This paper presents the details of an investigation on the shear behaviour of a recently developed, cold-formed steel beam known as LiteSteel Beam (LSB).The LSB section has a unique shape of a channel beam with two rectangular hollow flanges and is produced by a patented manufacturing process involving simultaneous cold-forming and dual electric resistance welding. In the present investigation, a series of numerical analyses based on three-dimensional finite element modeling and an experimental study were carried out to investigate the shear behaviour of 10 different LSB sections. It was found that the current design rules in cold-formed steel structures design codes are very conservative for the shear design of LiteSteel beams. Significant improvements to web shear buckling occurred due to the presence of rectangular hollow flanges while considerable post-buckling strength was also observed. Therefore the design rules were further modified to include the available post-buckling strength. Suitable design rules were also developed under the direct strength method format. This paper presents the details of this investigation and the results including the final design rules for the shear capacity of LSBs. It also presents new shear strength formulae for lipped channel beams based on the current design equations for shear strength given in AISI (2007) using the same approach used for LSBs.

Lateral-torsional buckling of cold-formed steel beams at ambient temperature

Cold-formed steel beams are increasingly used as floor joists and bearers in residential, industrial and commercial buildings. Their structural behaviour and moment capacities are influenced by lateral-torsional buckling and hence a research study was undertaken to investigate the lateral-torsional buckling behaviour of cold-formed steel lipped channel beams at ambient and elevated temperatures. For this purpose a finite element model of a simply supported cold-formed steel lipped channel beam under uniform bending was developed first and validated using available numberical and experimental results. It was then used in a detailed parametric study to simulate the lateral-torsional behaviour of cold-formed steel beams under varying conditions. The moment capacity results were then compared with the predictions from the current ambient temperature design rules in Australia, New Zealand, American and European codes for cold-formed steel structures. Some very interesting results have been obtained. European design rules are found to be conservative while Australian and American design rules are unsafe. This paper presents the results of finite element analyses for ambient temperature conditions, and the comparison with the current design rules.

Fixed argument pairings

A common scenario in many pairing-based cryptographic protocols is that one argument in the pairing is fixed as a long term secret key or a constant parameter in the system. In these situations, the runtime of Miller's algorithm can be significantly reduced by storing precomputed values that depend on the fixed argument, prior to the input or existence of the second argument. In light of recent developments in pairing computation, we show that the computation of the Miller loop can be sped up by up to 37 if precomputation is employed, with our method being up to 19.5 faster than the previous precomputation techniques.

IT-enhanced communication protocols for building project management

Purpose – Building project management requires real time flow of information between all the project team members or the supply chain members. In the present scenario, when project participants are geographically separated, adoption of Information Communication Technology (ICT) enables such effective communication. But strategic adoption of ICT requires that all the supply chain members follow the accepted methods of communication or the communication protocols. The majority of the construction organizations are small and medium enterprises (SMEs). This research, therefore, proposes to focus on developing IT-enhanced communication protocols for building project management by SMEs. Design/methodology/approach – The research adopts a sequential mixed methods approach, where data collection and analysis are conducted in both the quantitative and qualitative phases of research. Findings – The protocols are proposed as a “Strategic Model for Enhancing ICT Diffusion in Building Projects”. The framework for the model is discussed at three levels of study, i.e industry, organization, and people. Practical implications – While the research was conducted in an Indian context, the research outcome is envisaged to be widely applicable in other countries with due considerations. Originality/value – The developed framework has implications for national level bodies and academic institutions, organizations, people or project managers and is applicable at the international level after due considerations.

Experimental studies on the shear behaviour and strength of LiteSteel Beams

This paper presents the details of an experimental study on the shear behaviour and strength of a recently developed, cold-formed steel hollow flange channel beam known as LiteSteel Beam (LSB). The new LSB sections with rectangular hollow flanges are produced using a patented manufacturing process involving simultaneous cold-forming and dual electric resistance welding. They are commonly used as flexural members in buildings. However, no research has been undertaken on the shear behaviour of LSBs. Therefore a detailed experimental study involving 36 shear tests was undertaken to investigate the shear behaviour of 10 different LSB sections. Simply supported test specimens of LSBs with aspect ratios of 1.0 and 1.5 were loaded at midspan until failure using both single and back to back LSB arrangements. Test specimens were chosen such that all three types of shear failure (shear yielding, inelastic and elastic shear buckling) occurred in the tests. Comparison of experimental results with corresponding predictions from the current Australian and North American cold-formed steel design rules showed that the current 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. Appropriate improvements have been proposed for the shear strength of LSBs based on the design equations in the North American Specification. This paper presents the details of this experimental study and the results. When reduced height web side plates or only one web side plate was used, the shear capacity of LSB was reduced. Details of these tests and the results are also presented in this paper. Keywords: LiteSteel beam, Shear strength, Shear tests, Cold-formed steel structures, Direct strength method, Slender web, Hollow flanges.

Green cane impact on sugar processing : ISSCT process workshop 2008

The ISSCT Process Section workshop held in Réunion 20–23 October 2008 was attended by 51 delegates from 10 countries. The theme was Green cane impact on sugar processing. The workshop provided a valuable and timely opportunity to review and discuss the impact on factory operations and performance from a green cane supply that could include significant levels of trash. It was particularly relevant to those mills that were considering options to boost their biomass intake for increased co-generation capacity. Several of the speakers related their experiences with processing ‘whole of crop’ cane supplies through the factory. Speakers detailed the problems and increased losses that were incurred when processing cane with high trash levels. The consensus of the delegates was that the best scenario would involve a cane-cleaning plant at the factory so that only clean cane would be processed through the factory. The forum recommended that more research was required to address the issues of increased impurities in the process streams associated with high trash levels. Site visits to the two factories and a cane-delivery station were arranged as part of the workshop.