Outreach and Early Warning Systems (EWS) for the prevention of intensive care admission and death of critically ill adult patients on general hospital wards

BACKGROUND: Despite the fact that outreach and early warning systems (EWS) are an integral part of a hospital wide systems approach to improve the early identification and management of deteriorating patients on general hospital wards, the widespread implementation of these interventions in practice is not based on robust research evidence. OBJECTIVES: The primary objective was to determine the impact of critical care outreach services on hospital mortality rates. Secondary objectives included determining the effect of outreach services on intensive care unit (ICU) admission patterns, length of hospital stay and adverse events. SEARCH STRATEGY: The review authors searched the following electronic databases: EPOC Specialised Register, The Cochrane Central Register of Controlled Trials (CENTRAL) and other Cochrane databases (all on The Cochrane Library 2006, Issue 3), MEDLINE (1996-June week 3 2006), EMBASE (1974-week 26 2006), CINAHL (1982-July week 5 2006), First Search (1992-2005) and CAB Health (1990-July 2006); also reference lists of relevant articles, conference abstracts, and made contact with experts and critical care organisations for further information. SELECTION CRITERIA: Randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series designs (ITS) which measured hospital mortality, unanticipated ICU admissions, ICU readmissions, length of hospital stay and adverse events following implementation of outreach and EWS in a general hospital ward to identify deteriorating adult patients versus general hospital ward setting without outreach and EWS were included in the review. DATA COLLECTION AND ANALYSIS: Three review authors independently extracted data and two review authors assessed the methodological quality of the included studies. Meta-analysis was not possible due to heterogeneity. Summary statistics and descriptive summaries of primary and secondary outcomes are presented for each study. MAIN RESULTS: Two cluster-randomised control trials were included: one randomised at hospital level (23 hospitals in Australia) and one at ward level (16 wards in the UK). The primary outcome in the Australian trial (a composite score comprising incidence of unexpected cardiac arrests, unexpected deaths and unplanned ICU admissions) showed no statistical significant difference between control and medical emergency team (MET) hospitals (adjusted P value 0.640; adjusted odds ratio (OR) 0.98; 95% confidence interval (CI) 0.83 to 1.16). The UK-based trial found that outreach reduced in-hospital mortality (adjusted OR 0.52; 95% CI 0.32 to 0.85) compared with the control group. AUTHORS' CONCLUSIONS: The evidence from this review highlights the diversity and poor methodological quality of most studies investigating outreach. The results of the two included studies showed either no evidence of the effectiveness of outreach or a reduction in overall mortality in patients receiving outreach. The lack of evidence on outreach requires further multi-site RCT's to determine potential effectiveness.

Identifying early signs of aggression: psychometric properties of the cardiff infant contentiousness scale

Our aim was to develop an age-appropriate measure of early manifestations of aggression. We constructed a questionnaire about normative developmental milestones into which a set of items measuring infants’ use of physical force against people and expressed anger were included. These items comprise the Cardiff Infant Contentiousness Scale (CICS). Evidence for the reliability and validity of the CICS is provided from analyses of a sample of N5310 British infants, assessed at a mean age of 6 months as part of a larger longitudinal study of the development of aggression. The informants’ CICS ratings demonstrated reasonable levels of internal consistency and interrater agreement. Informants’ ratings were validated by observations of infants’ distress in response to restraint in a car seat. Longitudinal analyses revealed that contentiousness was stable over time and that contentiousness at 6 months predicted infants’ later use of force with peers. When used in the company of other methods, the simple four-item CICS scale could serve as a useful screen for early manifestations of aggressiveness in human infants.

An Autopilot Based on a Local Control Network Design for an Unmanned Surface Vehicle

Over recent years, a number of marine autopilots designed using linear techniques have underperformed owing to their inability to cope with nonlinear vessel dynamics. To this end, a new design framework for the development of nonlinear autopilots is proposed herein. Local control networks (LCNs) can be used in the design of nonlinear control systems. In this paper, a LCN approach is taken in the design of a nonlinear autopilot for controlling the nonlinear yaw dynamics of an unmanned surface vehicle known as Springer. It is considered the approach is the first of its kind to be used in marine control systems design. Simulation results are presented and the performance of the nonlinear autopilot is compared with that of an existing Springer linear quadratic Gaussian (LQG) autopilot using standard system performance criteria. From the results it can be concluded the LCN autopilot out performed that based on LQG techniques in terms of the selected criteria. Also it provided more energy saving control strategies and would thereby increase operational duration times for the vehicle during real-time missions.

Impact of weather conditions on electric vehicle performance

Seasonal and day-to-day variations in travel behaviour and performance of private passenger vehicles can be partially explained by changes in weather conditions. Likewise, in the electricity sector, weather affects energy demand. The impact of weather conditions on private passenger vehicle performance, usership statistics and travel behaviour has been studied for conventional, internal combustion engine, vehicles. Similarly, weather-driven variability in electricity demand and generation has been investigated widely. The aim of these analyses in both sectors is to improve energy efficiency, reduce consumption in peak hours and reduce greenhouse gas emissions. However, the potential effects of seasonal weather variations on electric vehicle usage have not yet been investigated. In Ireland the government has set a target requiring 10% of all vehicles in the transport fleet to be powered by electricity by 2020 to meet part of its European Union obligations to reduce greenhouse gas emissions and increase energy efficiency. This paper fills this knowledge gap by compiling some of the published information available for internal combustion engine vehicles and applying the lessons learned and results to electric vehicles with an analysis of historical weather data in Ireland and electricity market data in a number of what-if scenarios. Areas particularly impacted by weather conditions are battery performance, energy consumption and choice of transportation mode by private individuals.

An Analysis of the Effect of Electric Vehicle Charging on the Operation of the Single Electricity Market

To meet European Union renewable energy and greenhouse gas emissions reduction targets the Irish government set a target in 2008 that 10% of all vehicles in the transport fleet be powered by electricity by 2020. Similar electric vehicle targets have been introduced in other countries. However, reducing energy consumption and decreasing greenhouse gas emissions in transport is a considerable challenge due to heavy reliance on fossil fuels. In fact, transport in the Republic of Ireland in 2009 accounted for 29% of non-emissions trading scheme greenhouse gas emissions, 32% of energy-related greenhouse gas emissions, 21% of total greenhouse gas emissions and approximately 50% of energy-related non-emission trading scheme greenhouse gas emissions. In this paper the effect of electric vehicle charging on the operation of the single wholesale electricity market for the Republic of Ireland and Northern Ireland is analysed. The energy consumed, greenhouse gas emissions generated and changes to the wholesale price of electricity under peak and off-peak charging scenarios are quantified and discussed. Results from the study show that off-peak charging is more beneficial than peak charging.