Emergency department triage scales and their components : a systematic review of the scientific evidence

Emergency department (ED) triage is used to identify patients' level of urgency and treat them based on their triage level. The global advancement of triage scales in the past two decades has generated considerable research on the validity and reliability of these scales. This systematic review aims to investigate the scientific evidence for published ED triage scales. The following questions are addressed: 1. Does assessment of individual vital signs or chief complaints affect mortality during the hospital stay or within 30 days after arrival at the ED? 2. What is the level of agreement between clinicians' triage decisions compared to each other or to a gold standard for each scale (reliability)? 3. How valid is each triage scale in predicting hospitalization and hospital mortality? A systematic search of the international literature published from 1966 through March 31, 2009 explored the British Nursing Index, Business Source Premier, CINAHL, Cochrane Library, EMBASE, and PubMed. Inclusion was limited to controlled studies of adult patients (≥15 years) visiting EDs for somatic reasons. Outcome variables were death in ED or hospital and need for hospitalization (validity). Methodological quality and clinical relevance of each study were rated as high, medium, or low. The results from the studies that met the inclusion criteria and quality standards were synthesized applying the internationally developed GRADE system. Each conclusion was then assessed as having strong, moderately strong, limited, or insufficient scientific evidence. If studies were not available, this was also noted. We found ED triage scales to be supported, at best, by limited and often insufficient evidence. The ability of the individual vital signs included in the different scales to predict outcome is seldom, if at all, studied in the ED setting. The scientific evidence to assess interrater agreement (reliability) was limited for one triage scale and insufficient or lacking for all other scales. Two of the scales yielded limited scientific evidence, and one scale yielded insufficient evidence, on which to assess the risk of early death or hospitalization in patients assigned to the two lowest triage levels on a 5-level scale (validity).

Dynamic whole system testing of combined renewable heating systems : the current state of the art

Objective: For the evaluation of the energetic performance of combined renewable heating systems that supply space heat and domestic hot water for single family houses, dynamic behaviour, component interactions, and control of the system play a crucial role and should be included in test methods. Methods: New dynamic whole system test methods were developed based on “hardware in the loop” concepts. Three similar approaches are described and their differences are discussed. The methods were applied for testing solar thermal systems in combination with fossil fuel boilers (heating oil and natural gas), biomass boilers, and/or heat pumps. Results: All three methods were able to show the performance of combined heating systems under transient operating conditions. The methods often detected unexpected behaviour of the tested system that cannot be detected based on steady state performance tests that are usually applied to single components. Conclusion: Further work will be needed to harmonize the different test methods in order to reach comparable results between the different laboratories. Practice implications: A harmonized approach for whole system tests may lead to new test standards and improve the accuracy of performance prediction as well as reduce the need for field tests.

Photovoltaic System Design for a Contaminated Area in Falun – Comparison of South and East- West Layout

In this thesis the solar part of a large grid-connected photovoltaic system design has been done. The main purpose was to size and optimize the system and to present figures helping to evaluate the prospective project rationality, which can potentially be constructed on a contaminated area in Falun. The methodology consisted in PV market study and component selection, site analysis and defining suitable area for solar installation; and system configuration optimization based on PVsyst simulations and Levelized Cost of Energy calculations. The procedure was mainly divided on two parts, preliminary and detailed sizing. In the first part the objective was complex, which included the investigation of the most profitable component combination and system optimization due to tilt and row distance. It was done by simulating systems with different components and orientations, which were sized for the same 100kW inverter in order to make a fair comparison. For each simulated result a simplified LCOE calculation procedure was applied. The main results of this part show that with the price of 0.43 €/Wp thin-film modules were the most cost effective solution for the case with a great advantage over crystalline type in terms of financial attractiveness. From the results of the preliminary study it was possible to select the optimal system configuration, which was used in the detailed sizing as a starting point. In this part the PVsyst simulations were run, which included full scale system design considering near shadings created by factory buildings. Additionally, more complex procedure of LCOE calculation has been used here considered insurances, maintenance, time value of money and possible cost reduction due to the system size. Two system options were proposed in final results; both cover the same area of 66000 m2. The first one represents an ordinary South faced design with 1.1 MW nominal power, which was optimized for the highest performance. According to PVsyst simulations, this system should produce 1108 MWh/year with the initial investment of 835,000 € and 0.056 €/kWh LCOE. The second option has an alternative East-West orientation, which allows to cover 80% of occupied ground and consequently have 6.6 MW PV nominal power. The system produces 5388 MWh/year costs about 4500,000 € and delivers electricity with the same price of 0.056 €/kWh. Even though the EW solution has 20% lower specific energy production, it benefits mainly from lower relative costs for inverters, mounting and annual maintenance expenses. After analyzing the performance results, among the two alternatives none of the systems showed a clear superiority so there was no optimal system proposed. Both, South and East-West solutions have own advantages and disadvantages in terms of energy production profile, configuration, installation and maintenance. Furthermore, the uncertainty due to cost figures assumptions restricted the results veracity.

Testing of combined heating systems for small houses: Improved procedures for whole system test methods : Deliverable 2.3

Dynamic system test methods for heating systems were developed and applied by the institutes SERC and SP from Sweden, INES from France and SPF from Switzerland already before the MacSheep project started. These test methods followed the same principle: a complete heating system – including heat generators, storage, control etc., is installed on the test rig; the test rig software and hardware simulates and emulates the heat load for space heating and domestic hot water of a single family house, while the unit under test has to act autonomously to cover the heat demand during a representative test cycle. Within the work package 2 of the MacSheep project these similar – but different – test methods were harmonized and improved. The work undertaken includes:  • Harmonization of the physical boundaries of the unit under test. • Harmonization of the boundary conditions of climate and load. • Definition of an approach to reach identical space heat load in combination with an autonomous control of the space heat distribution by the unit under test. • Derivation and validation of new six day and a twelve day test profiles for direct extrapolation of test results.   The new harmonized test method combines the advantages of the different methods that existed before the MacSheep project. The new method is a benchmark test, which means that the load for space heating and domestic hot water preparation will be identical for all tested systems, and that the result is representative for the performance of the system over a whole year. Thus, no modelling and simulation of the tested system is needed in order to obtain the benchmark results for a yearly cycle. The method is thus also applicable to products for which simulation models are not available yet. Some of the advantages of the new whole system test method and performance rating compared to the testing and energy rating of single components are:  • Interaction between the different components of a heating system, e.g. storage, solar collector circuit, heat pump, control, etc. are included and evaluated in this test. • Dynamic effects are included and influence the result just as they influence the annual performance in the field. • Heat losses are influencing the results in a more realistic way, since they are evaluated under "real installed" and representative part-load conditions rather than under single component steady state conditions.   The described method is also suited for the development process of new systems, where it replaces time-consuming and costly field testing with the advantage of a higher accuracy of the measured data (compared to the typically used measurement equipment in field tests) and identical, thus comparable boundary conditions. Thus, the method can be used for system optimization in the test bench under realistic operative conditions, i.e. under relevant operating environment in the lab.   This report describes the physical boundaries of the tested systems, as well as the test procedures and the requirements for both the unit under test and the test facility. The new six day and twelve day test profiles are also described as are the validation results.