Development of process control methodology for tracking the quality and safety of pain, agitation and sedation management in critical care units

Objective: To develop sedation, pain, and agitation quality measures using process control methodology and evaluate their properties in clinical practice. Design: A Sedation Quality Assessment Tool was developed and validated to capture data for 12-hour periods of nursing care. Domains included pain/discomfort and sedation-agitation behaviors; sedative, analgesic, and neuromuscular blocking drug administration; ventilation status; and conditions potentially justifying deep sedation. Predefined sedation-related adverse events were recorded daily. Using an iterative process, algorithms were developed to describe the proportion of care periods with poor limb relaxation, poor ventilator synchronization, unnecessary deep sedation, agitation, and an overall optimum sedation metric. Proportion charts described processes over time (2 monthly intervals) for each ICU. The numbers of patients treated between sedation-related adverse events were described with G charts. Automated algorithms generated charts for 12 months of sequential data. Mean values for each process were calculated, and variation within and between ICUs explored qualitatively. Setting: Eight Scottish ICUs over a 12-month period. Patients: Mechanically ventilated patients. Interventions: None. Measurements and Main Results: The Sedation Quality Assessment Tool agitation-sedation domains correlated with the Richmond Sedation Agitation Scale score (Spearman [rho] = 0.75) and were reliable in clinician-clinician (weighted kappa; [kappa] = 0.66) and clinician-researcher ([kappa] = 0.82) comparisons. The limb movement domain had fair correlation with Behavioral Pain Scale ([rho] = 0.24) and was reliable in clinician-clinician ([kappa] = 0.58) and clinician-researcher ([kappa] = 0.45) comparisons. Ventilator synchronization correlated with Behavioral Pain Scale ([rho] = 0.54), and reliability in clinician-clinician ([kappa] = 0.29) and clinician-researcher ([kappa] = 0.42) comparisons was fair-moderate. Eight hundred twenty-five patients were enrolled (range, 59-235 across ICUs), providing 12,385 care periods for evaluation (range 655-3,481 across ICUs). The mean proportion of care periods with each quality metric varied between ICUs: excessive sedation 12-38%; agitation 4-17%; poor relaxation 13-21%; poor ventilator synchronization 8-17%; and overall optimum sedation 45-70%. Mean adverse event intervals ranged from 1.5 to 10.3 patients treated. The quality measures appeared relatively stable during the observation period. Conclusions: Process control methodology can be used to simultaneously monitor multiple aspects of pain-sedation-agitation management within ICUs. Variation within and between ICUs could be used as triggers to explore practice variation, improve quality, and monitor this over time

An ethnographic interpretation of the work environment within a creative culture in the advertising sector.

Purpose and rationale The purpose of the exploratory research is to provide a deeper understanding of how the work environment enhances or constrains organisational creativity (creativity and innovation) within the context of the advertising sector. The argument for the proposed research is that the contemporary literature is dominated by quantitative research instruments to measure the climate and work environment across many different sectors. The most influential theory within the extant literature is the componential theory of organisational creativity and innovation and is used as an analytical guide (Amabile, 1997; Figure 8) to conduct an ethnographic study within a creative advertising agency based in Scotland. The theory suggests that creative people (skills, expertise and task motivation) are influenced by the work environment in which they operate. This includes challenging work (+), work group supports (+), supervisory encouragement (+), freedom (+), sufficient resources (+), workload pressures (+ or -), organisational encouragement (+) and organisational impediments (-) which is argued enhances (+) or constrains (-) both creativity and innovation. An interpretive research design is conducted to confirm, challenge or extend the componential theory of organisational creativity and innovation (Amabile, 1997; Figure 8) and contribute to knowledge as well as practice. Design/methodology/approach The scholarly activity conducted within the context of the creative industries and advertising sector is in its infancy and research from the alternative paradigm using qualitative methods is limited which may provide new guidelines for this industry sector. As such, an ethnographic case study research design is a suitable methodology to provide a deeper understanding of the subject area and is consistent with a constructivist ontology and an interpretive epistemology. This ontological position is conducive to the researcher’s axiology and values in that meaning is not discovered as an objective truth but socially constructed from multiple realties from social actors. As such, ethnography is the study of people in naturally occurring settings and the creative advertising agency involved in the research is an appropriate purposive sample within an industry that is renowned for its creativity and innovation. Qualitative methods such as participant observation (field notes, meetings, rituals, social events and tracking a client brief), material artefacts (documents, websites, annual reports, emails, scrapbooks and photographic evidence) and focused interviews (informal and formal conversations, six taped and transcribed interviews and use of Survey Monkey) are used to provide a written account of the agency’s work environment. The analytical process of interpreting the ethnographic text is supported by thematic analysis (selective, axial and open coding) through the use of manual analysis and NVivo9 software Findings The findings highlight a complex interaction between the people within the agency and the enhancers and constraints of the work environment in which they operate. This involves the creative work environment (Amabile, 1997; Figure 8) as well as the physical work environment (Cain, 2012; Dul and Ceylan, 2011; Dul et al. 2011) and that of social control and power (Foucault, 1977; Gahan et al. 2007; Knights and Willmott, 2007). As such, the overarching themes to emerge from the data on how the work environment enhances or constrains organisational creativity include creative people (skills, expertise and task motivation), creative process (creative work environment and physical work environment) and creative power (working hours, value of creativity, self-fulfilment and surveillance). Therefore, the findings confirm that creative people interact and are influenced by aspects of the creative work environment outlined by Amabile (1997; Figure 8). However, the results also challenge and extend the theory to include that of the physical work environment and creative power. Originality/value/implications Methodologically, there is no other interpretive research that uses an ethnographic case study approach within the context of the advertising sector to explore and provide a deeper understanding of the subject area. As such, the contribution to knowledge in the form of a new interpretive framework (Figure 16) challenges and extends the existing body of knowledge (Amabile, 1997; Figure 8). Moreover, the contribution to practice includes a flexible set of industry guidelines (Appendix 13) that may be transferrable to other organisational settings.

An analysis of manufacturing simulation software.

As a management tool Similation Software deserves greater analysis from both an academic and industrial viewpoint. A comparative study of three packages was carried out from a 'first time' use approach. This allowed the ease of use and package features to be assessed using a simple theoretical benchmark manufacturing process. To back the use of these packages an objective survey on simulation use and package features was carried out within the manufacturing industry.This identified the use of simulation software, its' applicability and preception of user requirements thereby proposing an ideal package.

A decentralized batch-based group key management potocol for mobile Internet of Thngs (DBGK).

It is anticipated that constrained devices in the Internet of Things (IoT) will often operate in groups to achieve collective monitoring or management tasks. For sensitive and mission-critical sensing tasks, securing multicast applications is therefore highly desirable. To secure group communications, several group key management protocols have been introduced. However, the majority of the proposed solutions are not adapted to the IoT and its strong processing, storage, and energy constraints. In this context, we introduce a novel decentralized and batch-based group key management protocol to secure multicast communications. Our protocol is simple and it reduces the rekeying overhead triggered by membership changes in dynamic and mobile groups and guarantees both backward and forward secrecy. To assess our protocol, we conduct a detailed analysis with respect to its communcation and storage costs. This analysis is validated through simulation to highlight energy gains. The obtained results show that our protocol outperforms its peers with respect to keying overhead and the mobility of members.