Testing a model for developing, implementing and evaluating a strategy to improve the quality of nursing and midwifery care in an acute hospital trust.

Abstract:
Background: Health care organisations
worldwide are faced with the need to develop
and implement strategic organisational plans
to meet the challenges of modern health care.
There is a need for models for developing, implementing and evaluating strategic plans that engage practitioners, and make a measurable difference to the patients that they serve. These presentations describe the development, implementation and evaluation of such a model by a team of senior nurses and practice developers, to underpin a strategy for nursing and midwifery in an acute hospital trust. Developing a Strategy The PARIHS (Promoting Action on Research Implementation in Health Services) conceptual framework (Kitson et al, 1998) proposes that successful implementation of change in practice is a function of the interplay of three core elements: the level of evidence supporting the proposed change; the context or environment in which the change takes place, and the way in which change is facilitated. We chose to draw on this framework to develop our strategy and implementation plan (O’Halloran, Martin and Connolly, 2005). At the centre of the plan are ward managers. These professionals provide leadership for the majority of staff in the trust and so were seen to be a key group in the implementation process.

Hydrochemical and isotopic tracing of mixing dynamics and water quality evolution under pumping conditions in the mine shaft of the abandoned Frances Colliery, Scotland.

Since 1995, when pumps were withdrawn from deep mines in East Fife (Scotland), mine waters have been rebounding throughout the coalfield. Recently, it has become necessary to pump and treat these waters to prevent their uncontrolled emergence at the surface. However, even relatively shallow pumping to surface treatment lagoons of the initially chemically-stratified mine water from a shaft in the coastal Frances Colliery during two dynamic step-drawdown tests to establish the hydraulic characteristics of the system resulted in rapid breakdown of the stratification within 24 h and a poor pumped water quality with high dissolved Fe loading. Further, data are presented here of hydrochemical and isotopic sampling of the extended pump testing lasting up to several weeks. The use in particular of the environmental isotopes d18O, d2H, d34S, 3H, 13C and 14C alongside hydrochemical and hydraulic pump test data allowed characterisation of the Frances system dynamics, mixing patterns and water quality sources feeding into this mineshaft under continuously pumped conditions. The pumped water quality reflects three significant components of mixing: shallow freshwater, seawater, and leakage from the surface treatment lagoons. In spite of the early impact of recirculating lagoon waters on the hydrochemistries, the highest Fe loadings in the longer-term pumped waters are identified with a mixed freshwater–seawater component affected by pyrite oxidation/melanterite dissolution in the subsurface system.

Characterisation of virus transport and attenuation in epikarst using short pulse and prolonged injection multi-tracer testing

Attenuation processes controlling virus fate and transport in the vadose zone of karstified systems can strongly influence groundwater quality. This research compares the breakthrough of two bacteriophage tracers (H40/1 and T7), with contrasting properties, at subsurface monitoring points following application onto an overlying composite sequence of thin organic soil and weathered limestone (epikarst). Short pulse multi-tracer test results revealed that T7 (Source concentration, Co=1.8x106pfu/mL) and H40/1(Co=5.9x106pfu/mL) could reach sampling points 10m below ground less than 30 minutes after tracer application. Contrasting deposition rates, determined from simulated tracer responses, reflected the potential of the ground to differentially attenuate viruses. Prolonged application of both T7 (Co=2.3x104pfu/mL) and H40/1 (Co=1.3x105pfu/mL) over a five hour period during a subsequent test, in which ionic strength levels observed at monitoring points rose consistently, corresponded to a rapid rise in T7 levels, followed by a gradual decline before the end of tracer injection; this reflected reaction-limited deposition in the system. T7’s response contrasted with that of H40/1, whose concentration remained constant over a three hour period before declining dramatically prior to the end of tracer injection. Subsequent application of lower ionic strength tracer-free flush water generated a rapid rise in H40/1 levels and a more gradual release of T7. Results highlight the benefits of employing prolonged injection multi-tracer tests for identifying processes not apparent from conventional short pulse tests. Study findings demonstrate that despite rapid transport rates, the epikarst is capable of physicochemical filtration of viruses and their remobilization, depending on virus type and hydrochemical conditions.

Testing the stability of the benefit transfer function for discrete choice contingent valuation data

This paper examines the stability of the benefit transfer function across 42 recreational forests in the British Isles. A working definition of reliable function transfer is Put forward, and a suitable statistical test is provided. A novel split sample method is used to test the sensitivity of the models' log-likelihood values to the removal of contingent valuation (CV) responses collected at individual forest sites, We find that a stable function improves Our measure of transfer reliability, but not by much. We conclude that, in empirical Studies on transferability, considerations of function stability are secondary to the availability and quality of site attribute data. Modellers' can study the advantages of transfer function stability vis-a-vis the value of additional information on recreation site attributes. (c) 2008 Elsevier GmbH. All rights reserved.

Investigating Hydraulically Active Fractures in A Shallow Meta-Sedimentary Bedrock Aquifer Using Single Well Tracer Testing, Mount Stewart, Northern Ireland

Knowledge of groundwater flow/mass transport, in poorly productive aquifers which underlie over 65% of the island of Ireland, is necessary for effective management of catchment water quality and aquatic ecology. This research focuses on a fractured low-grade Ordovician/Silurian greywacke sequence which underlies approximately 25% of the northern half of Ireland. Knowledge of the unit’s hydrogeological properties remain largely restricted to localised single well open hole “transmissivity” values. Current hydrogeological conceptual models of the Greywacke view the bulk of groundwater flowing through fractures in an otherwise impermeable bedrock mass.
Core analysis permits fracture characterisation, although not all identified fractures may be involved in groundwater flow. Traditional in-situ hydraulic characterisation relies on cumbersome techniques such as packer testing or geophysical borehole logging (e.g. flowmeters). Queen’s University Belfast is currently carrying out hydraulic characterization of 16 boreholes at its Greywacke Hydrogeological Research Site at Mount Stewart, Northern Ireland.
Development of dye dilution methods, using a recently-developed downhole fluorometer, provided a portable, user-friendly, and inexpensive means of detecting hydraulically active intervals in open boreholes. Measurements in a 55m deep hole, three days following fluorescent dye injection, demonstrated the ability of the technique to detect two discrete hydraulically active intervals corresponding to zones identified by caliper and heat-pulse flowmeter logs. High resolution acoustic televiewer logs revealed the zones to correspond to two steeply dipping fractured intervals. Results suggest the rock can have effective porosities of the order of 0.1%.
Study findings demonstrate dye dilution’s utility in characterizing groundwater flow in fractured aquifers. Tests on remaining holes will be completed at different times following injection to identify less permeable fractures and develop an improved understanding of the structural controls on groundwater flow in the uppermost metres of competent bedrock.

Using solute/ micro organism comparative tracer testing to investigate hydrogeological heterogeneity in a fluvioglacial sand and gravel aquifer.

Groundwater drawn from fluvioglacial sand and gravel aquifers form the principal source of drinking water in many part of central Western Europe. High population densities and widespread organic agriculture in these same areas constitute hazards that may impact the microbiological quality of many potable supplies. Tracer testing comparing two similarly sized bacteria (E.coli and P. putida) and the smaller bacteriophage (H40/1) with the response of non-reactive solute tracer (uranine) at the decametre scale revealed that all tracers broke through up to 100 times more quickly than anticipated using conventional rules of thumb. All microbiological tracer responses were less disperse than the solute, although bacterial peak relative concentrations consistently exceeded those of the solute tracer at one sampling location reflecting exclusion processes influencing micro biological tracer migration. Relative recoveries of H40/1 and E.coli proved consistent at both monitoring wells, while responses of H40/1 and P.putida differed. Examination of exposures of the upper reaches of the aquifer in nearby sand and gravel quarries revealed the aquifer to consist of laterally extensive layers of open framework (OW) gravel enveloped in finer grained gravelly sand. Granulometric analysis of these deposits suggested that the OW gravel was up to two orders of magnitude more permeable than the surrounding deposits giving rise to the preferential flow paths. By contrast fine grained lenses of silty sand within the OW gravels are suspected to play an important role in the exclusion processes that permit solutes to access them but exclude larger micro organisms.

Optimization of image quality and dose for Varian aS500 electronic portal imaging devices (EPIDs)

This study was carried out to investigate whether the electronic portal imaging (EPI) acquisition process could be optimized, and as a result tolerance and action levels be set for the PIPSPro QC-3V phantom image quality assessment. The aim of the optimization process was to reduce the dose delivered to the patient while maintaining a clinically acceptable image quality. This is of interest when images are acquired in addition to the planned patient treatment, rather than images being acquired using the treatment field during a patient's treatment. A series of phantoms were used to assess image quality for different acquisition settings relative to the baseline values obtained following acceptance testing. Eight Varian aS500 EPID systems on four matched Varian 600C/D linacs and four matched Varian 2100C/D linacs were compared for consistency of performance and images were acquired at the four main orthogonal gantry angles. Images were acquired using a 6 MV beam operating at 100 MU min(-1) and the low-dose acquisition mode. Doses used in the comparison were measured using a Farmer ionization chamber placed at d(max) in solid water. The results demonstrated that the number of reset frames did not have any influence on the image contrast, but the number of frame averages did. The expected increase in noise with corresponding decrease in contrast was also observed when reducing the number of frame averages. The optimal settings for the low-dose acquisition mode with respect to image quality and dose were found to be one reset frame and three frame averages. All patients at the Northern Ireland Cancer Centre are now imaged using one reset frame and three frame averages in the 6 MV 100 MU min(-1) low-dose acquisition mode. Routine EPID QC contrast tolerance (+/-10) and action (+/-20) levels using the PIPSPro phantom based around expected values of 190 (Varian 600C/D) and 225 (Varian 2100C/D) have been introduced. The dose at dmax from electronic portal imaging has been reduced by approximately 28%, and while the image quality has been reduced, the images produced are still clinically acceptable.

Impact of Testing Procedure on Permeability of Compacted Soils

The commonly used British Standard constant head triaxial permeability (BS) test, for permeability testing of fine grained soils, is known to have a relatively long test duration. Consequently, a reduction in the required time for permeability test provides potential cost savings, to the construction industry (specifically, for use during Construction Quality Control (CQA) of landfill mineral liners). The purpose of this article is to investigate and evaluate alternative short duration testing methods for the measurement of the permeability of fine grained soils.

As part of the investigation the feasibility of an existing method of short duration permeability test, known as the Accelerated Permeability (AP) test was assessed and compared with permeability measured using British Standard method (BS) and Ramp Accelerated Permeability (RAP). Four different fine grained materials, of a variety of physical properties were compacted at various moisture contents to produced analogous samples for testing using three the three different methodologies. Fabric analysis was carried out on specimens derived from post-test samples using Mercury Intrusion Porosimetry (MIP) and Scanning Electron Microscope (SEM) to assess the effects of testing methodology on soil structure. Results showed that AP testing in general under predicts permeability values derived from the BS test due to large changes in structure of the soil caused by AP test methodology, which is also validated using MIP and SEM observations. RAP testing, in general provides an improvement to the AP test but still under-predicts permeability values. The potential savings in test duration are shown to be relatively minimal for both the AP and RAP tests.

Family-based associations in measures of psychological distress and quality of life in a cardiac screening clinic for inheritable cardiac diseases: a cross-sectional study

BACKGROUND: Family-based cardiac screening programmes for persons at risk for genetic cardiac diseases are now recommended. However, the psychological wellbeing and health related quality of life (QoL) of such screened patients is poorly understood, especially in younger patients. We sought to examine wellbeing and QoL in a representative group of adults aged 16 and over in a dedicated family cardiac screening clinic.

METHODS: Prospective survey of consecutive consenting patients attending a cardiac screening clinic, over a 12 month period. Data were collected using two health measurement tools: the Short Form 12 (version 2) and the Hospital Anxiety and Depression Scale (HADS), along with baseline demographic and screening visit-related data. The HADS and SF-12v.2 outcomes were compared by age group. Associations with a higher HADS score were examined using logistic regression, with multi-level modelling used to account for the family-based structure of the data.

RESULTS: There was a study response rate of 86.6%, with n=334 patients providing valid HADS data (valid response rate 79.5%), and data on n=316 retained for analysis. One-fifth of patients were aged under 25 (n=61). Younger patients were less likely than older to describe significant depression on their HADS scale (p<0.0001), although there were overall no difference between the prevalence of a significant HADS score between the younger and older age groups (18.0% vs 20.0%, p=0.73). Significant positive associates of a higher HADS score were having lower educational attainment, being single or separated, and being closely related to the family proband. Between-family variance in anxiety and depression scores was greater than within-family variance.

CONCLUSIONS: High levels of anxiety were seen amongst patients attending a family-based cardiac screening clinic.Younger patients also had high rates of clinically significant anxiety. Higher levels of anxiety and depression tends to run in families, and this has implications for family screening and intervention programmes.

RAS testing of colorectal carcinoma—a guidance document from the Association of Clinical Pathologists Molecular Pathology and Diagnostics Group

Analysis of colorectal carcinoma (CRC) tissue for KRAS codon 12 or 13 mutations to guide use of anti-epidermal growth factor receptor (EGFR) therapy is now considered mandatory in the UK. The scope of this practice has been recently extended because of data indicating that NRAS mutations and additional KRAS mutations also predict for poor response to anti-EGFR therapy. The following document provides guidance on RAS (i.e., KRAS and NRAS) testing of CRC tissue in the setting of personalised medicine within the UK and particularly within the NHS. This guidance covers issues related to case selection, preanalytical aspects, analysis and interpretation of such RAS testing.

Quality Assurance for GCxGC-FID, Accreditation for TPH CWG Protocol

A new technological approach in the analysis and forensic interpretation of Total Hydrocarbons in soils and waters using 2D Gas Chromatography method (GC-GC) was developed alongside environmental forensic and the assessment models to provide better customer products for the environmental industry.
The objective was to develop an analytical methodology for TPH CWG. Raw data from this method is then to be evaluated for forensic interpretation and risk assessment modelling. Access will be made available to the expertise in methods of forensic tracing contaminant sources, transport modelling, human health risk modelling and detailed quantitative risk assessment.
The quantification of internal standards was key to the development of this method. As the laboratory does not test for TPH in 1D, it was requested during INAB ISO 17025 audit to individually map out where each compound falls chromatographically in the 2D. This was done through comparing carbon equivalent numbers to the n-alkane carbons. This proved e.g. 2-methylnaphthalene has 11 carbons in its structure; its carbon equivalent is 12.84 , the result of which falls within the band of Aromatic eC12-eC16 as opposed to expected eC10-eC12. This was carried out for all 16 PAH (polyaromatic hydrocarbons) and BTEX (benzene, toluene, ethylbenzene and o, m and p-xylenes). The n-alkanes were also assigned to their corresponding aliphatic bands e.g. nC8 would be expected to be in nC8-nC10.
The method was validated through a designated systematic experimental protocol and was challenged with spikes of known concentration of hydrocarbon parameters such as recoveries, precision, bias and linearity. The method was verified by testing a certified reference material which was used as a proficiency round of testing for numerous laboratories.
It is hoped that the method will be used in conjunction with the analysis through Bonn Agreement with their OSINet group. This is a panel of experts and laboratories (including CLS) who forensically identify oil spill contamination from a water source.
This method can prove itself to be a robust method and benefit the industry for contaminated land and water but the method needs to be seen as separate from the regular 1D chromatography. It will help identify contaminants and assist consultants, regulators, clients and scientists valuable information not seen in 1D