A realistic evaluation of track and trigger systems and acute care training for early recognition and treatment of deteriorating ward-based patients: research protocol.

Aim The aim of the study is to evaluate factors that enable or constrain the implementation and service delivery of early warnings systems or acute care training in practice. Background To date there is limited evidence to support the effectiveness of acute care initiatives (early warning systems, acute care training, outreach) in reducing the number of adverse events (cardiac arrest, death, unanticipated Intensive Care admission) through increased recognition and management of deteriorating ward based patients in hospital [1-3]. The reasons posited are that previous research primarily focused on measuring patient outcomes following the implementation of an intervention or programme without considering the social factors (the organisation, the people, external influences) which may have affected the process of implementation and hence measured end-points. Further research which considers the social processes is required in order to understand why a programme works, or does not work, in particular circumstances [4]. Method The design is a multiple case study approach of four general wards in two acute hospitals where Early Warning Systems (EWS) and Acute Life-threatening Events Recognition and Treatment (ALERT) course have been implemented. Various methods are being used to collect data about individual capacities, interpersonal relationships and institutional balance and infrastructures in order to understand the intended and unintended process outcomes of implementing EWS and ALERT in practice. This information will be gathered from individual and focus group interviews with key participants (ALERT facilitators, nursing and medical ALERT instructors, ward managers, doctors, ward nurses and health care assistants from each hospital); non-participant observation of ward organisation and structure; audit of patients' EWS charts and audit of the medical notes of patients who deteriorated during the study period to ascertain whether ALERT principles were followed. Discussion & progress to date This study commenced in January 2007. Ethical approval has been granted and data collection is ongoing with interviews being conducted with key stakeholders. The findings from this study will provide evidence for policy-makers to make informed decisions regarding the direction for strategic and service planning of acute care services to improve the level of care provided to acutely ill patients in hospital. References 1. Esmonde L, McDonnell A, Ball C, Waskett C, Morgan R, Rashidain A et al. Investigating the effectiveness of Critical Care Outreach Services: A systematic review. Intensive Care Medicine 2006; 32: 1713-1721 2. McGaughey J, Alderdice F, Fowler R, Kapila A, Mayhew A, Moutray M. Outreach and Early Warning Systems for the prevention of Intensive Care admission and death of critically ill patients on general hospital wards. Cochrane Database of Systematic Reviews 2007, Issue 3. www.thecochranelibrary.com 3. Winters BD, Pham JC, Hunt EA, Guallar E, Berenholtz S, Pronovost PJ (2007) Rapid Response Systems: A systematic review. Critical Care Medicine 2007; 35 (5): 1238-43 4. Pawson R and Tilley N. Realistic Evaluation. London; Sage: 1997

A computational intelligent approach to multi-factor analysis of violent crime information systems

Various scientific studies have explored the causes of violent behaviour from different perspectives, with psychological tests, in particular, applied to the analysis of crime factors. The relationship between bi-factors has also been extensively studied including the link between age and crime. In reality, many factors interact to contribute to criminal behaviour and as such there is a need to have a greater level of insight into its complex nature. In this article we analyse violent crime information systems containing data on psychological, environmental and genetic factors. Our approach combines elements of rough set theory with fuzzy logic and particle swarm optimisation to yield an algorithm and methodology that can effectively extract multi-knowledge from information systems. The experimental results show that our approach outperforms alternative genetic algorithm and dynamic reduct-based techniques for reduct identification and has the added advantage of identifying multiple reducts and hence multi-knowledge (rules). Identified rules are consistent with classical statistical analysis of violent crime data and also reveal new insights into the interaction between several factors. As such, the results are helpful in improving our understanding of the factors contributing to violent crime and in highlighting the existence of hidden and intangible relationships between crime factors.

Confined Site Construction: A qualitative investigation of critical issues affecting management of Health and Safety

The construction industry is inherently risky, with a significant number of accidents and disasters occurring, particularly on confined construction sites. This research investigates and identifies the various issues affecting successful management of health and safety in confined construction sites. The rationale is that identifying the issues would assist the management of health and safety particularly in inner city centres which are mostly confined sites. Using empiricism epistemology, the methodology was based on qualitative research approach by means of multiple case studies in three different geographical locations of Ireland, UK and USA. Data on each case study were collected through individual interviews and focus group discussion with project participants. The findings suggest that three core issues are the underlying factors affecting management of health and safety on confined construction sites. It include, (i) lack of space, (ii) problem of co-ordination and management of site personnel, and (iii) overcrowding of workplace. The implication of this is that project teams and their organisations should see project processes from a holistic point of view, as a unified single system, where quick intervention in solving a particular issue should be the norm, so as not to adversely affect interrelated sequence of events in project operations. Proactive strategies should be devised to mitigate these issues and may include detail project programming, space management, effective constructability review and efficient co-ordination of personnel, plant and materials among others. The value of this research is to aid management and operation of brownfield sites by identifying issues impacting on health and safety management in project process.

Strategies for Effective Management of Health and Safety in Confined Site Construction

The overall aim of this research is to identify and catalogue the numerous managerial strategies for effective management of health and safety on a confined, urban, construction site. A mixed methods methodology was adopted using interviews and focus group discussions on three selected case studies of confined construction sites. In addition to these, a questionnaire survey was used based on the findings from the interviews and the focus group discussions. The top five key strategies include (1) Employ safe system of work plans to mitigate personnel health and safety issues; (2) Inform personnel, before starting on-site, of the potential issues using site inductions; (3) Effective communication among site personnel; (4) Draft and implement an effective design site layout prior to starting on-site; and (5) Use of banksman (traffic co-ordinator) to segregate personnel from vehicular traffic. The construction sector is one of the leading industries in accident causation and with the continued development and regeneration of our urban centres, confined site construction is quickly becoming the norm - an environment which only fuels accident creation within the construction sector. This research aids on-site management that requires direction and assistance in the identification and implementation of key strategies for the management of health and safety, particularly in confined construction site environments.

Diagnosis and management of congenital and idiopathic erythrocytosis

An erythrocytosis occurs when there is an increased red-cell mass. The causes of erythrocytosis are divided into primary, when there is an intrinsic defect in the erythroid cell, and secondary, when the cause is extrinsic to the erythroid cell. An idiopathic erythrocytosis occurs when the increased red-cell mass has no identifiable cause. Primary and secondary defects can be further classified as either congenital or acquired causes. The diagnostic pathway starts with a careful history and examination followed by measurement of the erythropoietin (EPO) levels. This allows a division of those patients with a low EPO level, who can then be investigated for primary causes of erythrocytosis, and those with a normal or high EPO level, where the oxygen-sensing pathway needs to be explored further. Physiological studies in those with congenital defects in the oxygen-sensing pathway show many changes in the downstream metabolism adapting to the defect, which has a bearing on the management of the disorders. Low-dose aspirin and venesection to an achievable target are the main therapeutic options that can be considered in the management of erythrocytosis. Specific guidance on venesection options should be considered with certain causes such as high oxygen-affinity hemoglobins.

Phase Equilibria of Binary and Ternary Systems Containing ILs, Dodecane, and Cyclohexanecarboxylic Acid

This paper reports both the binary and ternary phase behavior of ionic liquids for extracting cyclohexanecarboxylic acid (CCA) from dodecane. This system is a model for the extraction of acids representative of naphthenic acids found in crude oils. In order to develop an effective ternary liquid-liquid extraction system the preliminary selection of ionic liquids was based on CCA miscibility and the dodecane immiscibility with selected ILs. A wide range of ILs based on different cations, anions, cation alkyl-chain length, as well as the effect of temperature on the overall fluid phase behavior is reported. Factors such as variation of cation group, anion effect, alkyl-chain length, and temperature all impact the extraction to various degrees. The largest effects were found to be the lipophilicity of the IL cation and the co-ordination ability of the anion. While CCA capacity increased with lipophilicity of the cation, as did the dodecane. Highly coordinating anions such as trifluoroacetate and triflate demonstrated that highly efficient extraction could be obtained producing favorable tie-lines in the ternary phase diagram. Overall, this study demonstrates that ILs can selectively extract acids from hydrocarbon streams and offers possible treatment solutions for problems associated with the processing of high acid crude oils.

Quantitative Analysis of Fault and Fracture Systems and their Impact on Groundwater Flow in Irish Bedrock Aquifers

Fault and fracture systems are the most important store and pathway for groundwater in Ireland’s bedrock aquifers, either directly as conductive flow structures, or indirectly as the locus for the development of dolomitised limestone and karst. This article presents the preliminary results of a study involving the quantitative analysis of fault and fracture systems in the broad range of Irish bedrock types and a consideration of their impact on groundwater flow. The principal aims of the project are to develop generic conceptual models for different fault/fracture systems in different lithologies and at different depths, and to link them to observed groundwater behaviour. Here we briefly describe the geometrical characteristics of the main post-Devonian fault/fracture systems controlling groundwater flow from field observations at outcrops, quarries and mines. The structures range from Lower Carboniferous normal faults through to Variscan-related faults and veins, with the most recent structures including Tertiary strike-slip faults and ubiquitous uplift-related joint systems. The geometrical characteristics of different fault/fracture systems combined with observations of groundwater behaviour in both quarry and mine localities, can be linked to general flow and transport conceptualisations of Irish fractured bedrock. Most importantly they also provide a basis for relating groundwater flow to particular fault/fracture systems and their expression with depth and within different lithological sequences, as well as their regional variability.