Test of a Smock System on CPR Primary Emergency Measures and Medical Errors During Simulated Emergencies

Rates of survival of victims of sudden cardiac arrest (SCA) using cardio pulmonary resuscitation (CPR) have shown little improvement over the past three decades. Since registered nurses (RNs) comprise the largest group of healthcare providers in U.S. hospitals, it is essential that they are competent in performing the four primary measures (compression, ventilation, medication administration, and defibrillation) of CPR in order to improve survival rates of SCA patients. The purpose of this experimental study was to test a color-coded SMOCK system on:1) time to implement emergency patient care measures 2) technical skills performance 3) number of medical errors, and 4) team performance during simulated CPR exercises. The study sample was 260 RNs (M 40 years, SD=11.6) with work experience as an RN (M 7.25 years, SD=9.42).Nurses were allocated to a control or intervention arm consisting of 20 groups of 5-8 RNs per arm for a total of 130 RNs in each arm. Nurses in each study arm were given clinical scenarios requiring emergency CPR. Nurses in the intervention group wore different color labeled aprons (smocks) indicating their role assignment (medications, ventilation, compression, defibrillation, etc) on the code team during CPR. Findings indicated that the intervention using color-labeled smocks for pre-assigned roles had a significant effect on the time nurses started compressions (t=3.03, p=0.005), ventilations (t=2.86, p=0.004) and defibrillations (t=2.00, p=.05) when compared to the controls using the standard of care. In performing technical skills, nurses in the intervention groups performed compressions and ventilations significantly better than those in the control groups. The control groups made significantly (t=-2.61, p=0.013) more total errors (7.55 SD 1.54) than the intervention group (5.60, SD 1.90). There were no significant differences in team performance measures between the groups. Study findings indicate use of colored labeled smocks during CPR emergencies resulted in: shorter times to start emergency CPR; reduced errors; more technical skills completed successfully; and no differences in team performance.

The drivers of perception: Identifying the driving factors of resident perceptions of municipal service quality in cities of South Florida

The idea of comparative performance assessment is crucial. Recent study findings show that in South Florida the use by most municipalities of external benchmarks for performance comparison is virtually non-existent. On one level this study sought to identify the factors impacting resident perceptions of municipal service quality. On a different and more practical level, this study sought to identify a core set of measures that could serve for multi jurisdictional comparisons of performance. ^ This study empirically tested three groups of hypotheses. Data were collected via custom designed survey instruments from multiple jurisdictions, representing diverse socioeconomic backgrounds, and across two counties. A second layer of analysis was conducted on municipal budget documents for the presence of performance measures. A third layer of analysis was conducted via face-to-face interviews with residents at the point of service delivery. Research questions were analyzed using descriptive and inferential statistic methodologies. ^ Results of survey data yielded inconsistent findings. In absolute aggregated terms, the use of sociological determinants to guide inquiry failed to yield conclusive answers regarding the factors impacting resident perceptions of municipal service quality. At disaggregated community levels, however, definite differences emerged but these had weak predictive ability. More useful were the findings of performance measures reporting via municipal budget documents and analyses of interviews with residents at the point of service delivery. Regardless of socio-economic profile, neighborhood characteristics, level of civic engagement or type of community, the same aspects were important to citizens when making assessments of service quality. For parks and recreation, respondents most frequently cited maintenance, facility amenities, and program offerings as important while for garbage collection services timely and consistent service delivery mattered most. Surprisingly municipalities participating in the study track performance data on items indicated as important by citizen assessments but regular feed back from residents or reporting to the same is rarely done. ^ The implications of these findings suggest that endeavors, such as the one undertaken in this study, can assist in determining a core set of measures for cross jurisdictional comparisons of municipal service quality, improving municipal delivery of services, and to communicate with the public. ^

The mathematics anxiety of bilingual community college students

Math anxiety levels and performance outcomes were compared for bilingual and monolingual community college Intermediate Algebra students attending a culturally diverse urban commuter college. Participants (N = 618, 250 men, 368 women; 361 monolingual, 257 bilingual) completed the Abbreviated Math Anxiety Scale (AMAS) and a demographics instrument. Bilingual and monolingual students reported comparable mean AMAS scores (20.6 and 20.7, respectively) and comparable proportions of math anxious individuals (50% and 48%, respectively). Factor analysis of AMAS scores, using principal component analysis by varimax rotation, yielded similar two-factor structures for both populations -- assessment and learning content -- accounting for 65.6% of the trace for bilingual AMAS scores. Statistically significant predictor variables for levels of math anxiety for the bilingual participants included (a) preparatory course enrollment (β = .236, p = .041) with those enrolled in prior preparatory courses scoring higher, (b) education major (β = .285, p = .018) with education majors scoring higher, and (c) business major (β = .252, p = .032) with business majors scoring higher. One statistically significant predictor variable emerged for monolingual students, gender (β = -.085, p = .001) with females ranking higher. Age, income, race, ethnicity, U.S. origin, science or health science majors did not emerge as statistically significant predictor variables for either group.^ Similarities between monolingual and bilingual participants included statistically significant negative linear correlations between AMAS scores and course grades for both bilingual (r = -.178, p = .017) and monolingual participants (r = -.203, p = .001). Differences included a statistically significant linear correlation between AMAS scores and final exam grades for monolingual participants only (r = -.253, p < .0009) despite no statistically significant difference in the strength the linear relationship of the AMAS scores and the final exam scores between groups, z = 1.35, p = .1756.^ The findings show that bilingual and monolingual students report math anxiety similarly and that math anxiety has similar associations with performance measures, despite differences between predictor variables. One of the first studies on the math anxiety of bilingual community college students, the results suggest recommendations for researchers and practitioners.^

A theory of constraints service systems improvement method: Case of the airline turnaround problem

This dissertation develops a process improvement method for service operations based on the Theory of Constraints (TOC), a management philosophy that has been shown to be effective in manufacturing for decreasing WIP and improving throughput. While TOC has enjoyed much attention and success in the manufacturing arena, its application to services in general has been limited. The contribution to industry and knowledge is a method for improving global performance measures based on TOC principles. The method proposed in this dissertation will be tested using discrete event simulation based on the scenario of the service factory of airline turnaround operations. To evaluate the method, a simulation model of aircraft turn operations of a U.S. based carrier was made and validated using actual data from airline operations. The model was then adjusted to reflect an application of the Theory of Constraints for determining how to deploy the scarce resource of ramp workers. The results indicate that, given slight modifications to TOC terminology and the development of a method for constraint identification, the Theory of Constraints can be applied with success to services. Bottlenecks in services must be defined as those processes for which the process rates and amount of work remaining are such that completing the process will not be possible without an increase in the process rate. The bottleneck ratio is used to determine to what degree a process is a constraint. Simulation results also suggest that redefining performance measures to reflect a global business perspective of reducing costs related to specific flights versus the operational local optimum approach of turning all aircraft quickly results in significant savings to the company. Savings to the annual operating costs of the airline were simulated to equal 30% of possible current expenses for misconnecting passengers with a modest increase in utilization of the workers through a more efficient heuristic of deploying them to the highest priority tasks. This dissertation contributes to the literature on service operations by describing a dynamic, adaptive dispatch approach to manage service factory operations similar to airline turnaround operations using the management philosophy of the Theory of Constraints.

A multi-method approach for the assessment of composite indices and rankings

There is growing popularity in the use of composite indices and rankings for cross-organizational benchmarking. However, little attention has been paid to alternative methods and procedures for the computation of these indices and how the use of such methods may impact the resulting indices and rankings. This dissertation developed an approach for assessing composite indices and rankings based on the integration of a number of methods for aggregation, data transformation and attribute weighting involved in their computation. The integrated model developed is based on the simulation of composite indices using methods and procedures proposed in the area of multi-criteria decision making (MCDM) and knowledge discovery in databases (KDD). The approach developed in this dissertation was automated through an IT artifact that was designed, developed and evaluated based on the framework and guidelines of the design science paradigm of information systems research. This artifact dynamically generates multiple versions of indices and rankings by considering different methodological scenarios according to user specified parameters. The computerized implementation was done in Visual Basic for Excel 2007. Using different performance measures, the artifact produces a number of excel outputs for the comparison and assessment of the indices and rankings. In order to evaluate the efficacy of the artifact and its underlying approach, a full empirical analysis was conducted using the World Bank's Doing Business database for the year 2010, which includes ten sub-indices (each corresponding to different areas of the business environment and regulation) for 183 countries. The output results, which were obtained using 115 methodological scenarios for the assessment of this index and its ten sub-indices, indicated that the variability of the component indicators considered in each case influenced the sensitivity of the rankings to the methodological choices. Overall, the results of our multi-method assessment were consistent with the World Bank rankings except in cases where the indices involved cost indicators measured in per capita income which yielded more sensitive results. Low income level countries exhibited more sensitivity in their rankings and less agreement between the benchmark rankings and our multi-method based rankings than higher income country groups.

Essays on the Impact of Stakeholders' Sentiment on the Financial Decision Making Process

The most important factor that affects the decision making process in finance is the risk which is usually measured by variance (total risk) or systematic risk (beta). Since investors' sentiment (whether she is an optimist or pessimist) plays a very important role in the choice of beta measure, any decision made for the same asset within the same time horizon will be different for different individuals. In other words, there will neither be homogeneity of beliefs nor the rational expectation prevalent in the market due to behavioral traits. This dissertation consists of three essays. In the first essay, Investor Sentiment and Intrinsic Stock Prices, a new technical trading strategy is developed using a firm specific individual sentiment measure. This behavioral based trading strategy forecasts a range within which a stock price moves in a particular period and can be used for stock trading. Results show that sample firms trade within a range and show signals as to when to buy or sell. The second essay, Managerial Sentiment and the Value of the Firm, examines the effect of managerial sentiment on the project selection process using net present value criterion and also effect of managerial sentiment on the value of firm. Findings show that high sentiment and low sentiment managers obtain different values for the same firm before and after the acceptance of a project. The last essay, Investor Sentiment and Optimal Portfolio Selection, analyzes how the investor sentiment affects the nature and composition of the optimal portfolio as well as the performance measures. Results suggest that the choice of the investor sentiment completely changes the portfolio composition, i.e., the high sentiment investor will have a completely different choice of assets in the portfolio in comparison with the low sentiment investor. The results indicate the practical application of behavioral model based technical indicators for stock trading. Additional insights developed include the valuation of firms with a behavioral component and the importance of distinguishing portfolio performance based on sentiment factors.

Ecological indicators for system-wide assessment of the greater everglades ecosystem restoration program

Developing scientifically credible tools for measuring the success of ecological restoration projects is a difficult and a non-trivial task. Yet, reliable measures of the general health and ecological integrity of ecosystems are critical for assessing the success of restoration programs. The South Florida Ecosystem Restoration Task Force (Task Force), which helps coordinate a multi-billion dollar multi-organizational effort between federal, state, local and tribal governments to restore the Florida Everglades, is using a small set of system-wide ecological indicators to assess the restoration efforts. A team of scientists and managers identified eleven ecological indicators from a field of several hundred through a selection process using 12 criteria to determine their applicability as part of a system-wide suite. The 12 criteria are: (1) is the indicator relevant to the ecosystem? (2) Does it respond to variability at a scale that makes it applicable to the entire system? (3) Is the indicator feasible to implement and is it measureable? (4) Is the indicator sensitive to system drivers and is it predictable? (5) Is the indicator interpretable in a common language? (6) Are there situations where an optimistic trend with regard to an indicator might suggest a pessimistic restoration trend? (7) Are there situations where a pessimistic trend with regard to an indicator may be unrelated to restoration activities? (8) Is the indicator scientifically defensible? (9) Can clear, measureable targets be established for the indicator to allow for assessments of success? (10) Does the indicator have specificity to be able to result in corrective action? (11) What level of ecosystem process or structure does the indicator address? (12) Does the indicator provide early warning signs of ecological change? In addition, a two page stoplight report card was developed to assist in communicating the complex science inherent in ecological indicators in a common language for resource managers, policy makers and the public. The report card employs a universally understood stoplight symbol that uses green to indicate that targets are being met, yellow to indicate that targets have not been met and corrective action may be needed and red to represent that targets are far from being met and corrective action is required. This paper presents the scientific process and the results of the development and selection of the criteria, the indicators and the stoplight report card format and content. The detailed process and results for the individual indicators are presented in companion papers in this special issue of Ecological Indicators.

A large-scale dynamic vector and raster data visualization geographic information system based on parallel map tiling

With the exponential increasing demands and uses of GIS data visualization system, such as urban planning, environment and climate change monitoring, weather simulation, hydrographic gauge and so forth, the geospatial vector and raster data visualization research, application and technology has become prevalent. However, we observe that current web GIS techniques are merely suitable for static vector and raster data where no dynamic overlaying layers. While it is desirable to enable visual explorations of large-scale dynamic vector and raster geospatial data in a web environment, improving the performance between backend datasets and the vector and raster applications remains a challenging technical issue. This dissertation is to implement these challenging and unimplemented areas: how to provide a large-scale dynamic vector and raster data visualization service with dynamic overlaying layers accessible from various client devices through a standard web browser, and how to make the large-scale dynamic vector and raster data visualization service as rapid as the static one. To accomplish these, a large-scale dynamic vector and raster data visualization geographic information system based on parallel map tiling and a comprehensive performance improvement solution are proposed, designed and implemented. They include: the quadtree-based indexing and parallel map tiling, the Legend String, the vector data visualization with dynamic layers overlaying, the vector data time series visualization, the algorithm of vector data rendering, the algorithm of raster data re-projection, the algorithm for elimination of superfluous level of detail, the algorithm for vector data gridding and re-grouping and the cluster servers side vector and raster data caching.

Integrated Ecological Modeling and Decision Analysis Within the Everglades Landscape

Planning for complex ecosystem restoration projects involves integrating ecological modeling with analysis of performance trade-offs among restoration alternatives. The authors used the Everglades Landscape Model and Multi-Criteria Decision Analysis to explore the effect of simulated ecosystem performance, risk preferences, and criteria weights on the ranking of three alternatives to restoring overland sheet flow in the Everglades. The ecological model outputs included both hydrologic and water quality criteria. Results were scored in the decision analysis framework, highlighting the trade-offs between hydrologic restoration and water quality constraints. Given equal weighting of performance measures, the alternative with more homogenous sheet flow was preferred over other alternatives, despite evidence of some localized eutrophication risk.

Adventures and Misfortunes in Macondo: Rehabilitation of the Cienaga Grande

We describe trajectories of selected ecological indicators used as performance measures to evaluate the success of a mangrove rehabilitation project in the Ciénaga Grande de Santa Marta (CGSM) Delta-Lagoon complex, Colombia, as result of freshwater diversions initiated in 1995. There is a significant reduction in soil and water column salinity in all sampling stations following the hydraulic reconnection of the Clarín and Aguas Negras channels to the Magdalena River. Soil intersticial water salinity (depth: 0.5 m) (7 stations) and water column salinity (0.5 m) (10 stations) values declined significantly (soil <30 g kg-1; water <10 g kg-1) from 1994 to 2000. During 1994 soil interstitial water salinity ranged from 40 g kg-1 (Rinconada) to 100 g kg-1 (KM 13), while water column salinity fluctuated between 25-35 g kg-1 for most of the sampling stations. This salinity reduction increased mangrove forest regeneration promoting a net gain of 99 km2 from 1995 to 1999. The high precipitation recorded in 1995 and 1999 caused by El Niño-La Niña (ENSO), coinciding with the channels rehabilitation, influenced rapid mangrove regeneration. The lack of economic investment in the maintenance of the diversion structures from 2001 to 2004 caused a salinity increase affecting negatively already restored vegetation. A sustainable effort from the international community and the Colombian government is needed to maintain the strategic social and economic benefits reached until 2000 in the CGSM region.

Alligators and crocodiles as indicators for restoration of Everglades ecosystems

Alligators and crocodiles integrate biological impacts of hydrological operations, affecting them at all life stages through three key aspects of Everglades ecology: (1) food webs, (2) diversity and productivity, and (3) freshwater flow. Responses of crocodilians are directly related to suitability of environmental conditions and hydrologic change. Correlations between biological responses and environmental conditions contribute to an understanding of species’ status and trends over time. Positive or negative trends of crocodilian populations relative to hydrologic changes permit assessment of positive or negative trends in restoration. The crocodilian indicator uses monitoring parameters (performance measures) that have been shown to be both effective and efficient in tracking trends. The alligator component uses relative density (reported as an encounter rate), body condition, and occupancy rates of alligator holes; the crocodile component uses juvenile growth and hatchling survival. We hypothesize that these parameters are correlated with hydrologic conditions including depth, duration, timing, spatial extent and water quality. Salinity is a critical parameter in estuarine habitats. Assessments of parameters defined for crocodilian performance measures support these hypotheses. Alligators and crocodiles are the charismatic megafauna of the Everglades. They are both keystone and flagship species to which the public can relate. In addition, the parameters used to track trends are easy to understand. They provide answers to the following questions: How has the number of alligators or crocodiles changed? Are the animals fatter or thinner than they should be? Are the animals in the places (in terms of habitat and geography) where they should be? As surely as there is no other Everglades, no other single species defines the Everglades as does the American alligator. The Everglades is the only place in the world where both alligators and crocodiles exist. Crocodilians clearly respond to changes in hydrologic parameters of management interest. These relationships are easy to communicate and mean something to managers, decision makers, and the public. Having crocodilians on the list of system-wide, general indicators provides us with one of the most powerful tools we have to communicate progress of ecosystem restoration in Greater Everglades ecosystems to diverse audiences.

Roseate spoonbill reproduction as an indicator for restoration of the Everglades and the Everglades estuaries

Ecological monitoring is key to successful ecosystem restoration. Because all components within an ecosystem cannot be monitored, it is important to select indicators that are representative of the system, integrate system responses, clearly respond to system change, can be effectively and efficiently monitored, and are easily communicated. The roseate spoonbill is one ecological indicator species that meets these criteria within the Everglades ecosystem. Monitoring of roseate spoonbills in Florida Bay over the past 70 years has shown that aspects of this species’ reproduction respond to changes in hydrology and corresponding changes in prey abundance and availability. This indicator uses nesting location, nest numbers and nesting success in response to food abundance and availability. In turn, prey abundance is a function of hydrological conditions (especially water depth) and salinity. Metrics and targets for these performance measures were established based on previous findings. Values of each metric were translated into indices and identified as stoplight colors with green indicating that a given target has been met, yellow indicating that conditions are below the target, but within an acceptable range of it, and red indicating the measure is performing poorly in relation to the target.

Relationships Between Hydrology and Soils Describe Vegetation Patterns in Seasonally Flooded Tree Islands of the Southern Everglades, Florida

Tree island ecosystems are important and distinct features of Florida Everglades wetlands. We described the inter-relationships among abiotic factors describing seasonally flooded tree islands and characterized plant–soil relationships in tree islands occurring in a relatively unimpacted area of the Everglades. We used Principal Components Analysis (PCA) to reduce our multi-factor dataset, quantified forest structure and vegetation nutrient dynamics, and related these vegetation parameters to PCA summary variables using linear regression analyses. We found that, of the 21 abiotic parameters used to characterize the ecosystem structure of seasonally flooded tree islands, 13 parameters were significantly correlated with four principal components, and they described 78% of the variance among the study islands. Most variation was described by factors related to soil oxidation and hydrology, exemplifying the sensitivity of tree island structure to hydrologic conditions. PCA summary variables describing tree island structure were related to variability in Chrysobalanus icaco (L.) canopy cover, Ilex cassine (L.) and Salix caroliniana (Michx.) canopy cover, Myrica cerifera (L.) plot frequency, litter turnover, % phosphorus resorption of co-dominant species, and nitrogen nutrient-use efficiency. This study supported findings that vegetation characteristics can be sensitive indicators of variability in tree island ecosystem structure. This study produced valuable, information which was used to recommend ecological targets (i.e. restoration performance measures) for seasonally flooded tree islands in more impacted regions of the Everglades landscape.

Advanced methodologies in dynamic traffic assignment modeling of managed lanes

Managed lane strategies are innovative road operation schemes for addressing congestion problems. These strategies operate a lane (lanes) adjacent to a freeway that provides congestion-free trips to eligible users, such as transit or toll-payers. To ensure the successful implementation of managed lanes, the demand on these lanes need to be accurately estimated. Among different approaches for predicting this demand, the four-step demand forecasting process is most common. Managed lane demand is usually estimated at the assignment step. Therefore, the key to reliably estimating the demand is the utilization of effective assignment modeling processes. ^ Managed lanes are particularly effective when the road is functioning at near-capacity. Therefore, capturing variations in demand and network attributes and performance is crucial for their modeling, monitoring and operation. As a result, traditional modeling approaches, such as those used in static traffic assignment of demand forecasting models, fail to correctly predict the managed lane demand and the associated system performance. The present study demonstrates the power of the more advanced modeling approach of dynamic traffic assignment (DTA), as well as the shortcomings of conventional approaches, when used to model managed lanes in congested environments. In addition, the study develops processes to support an effective utilization of DTA to model managed lane operations. ^ Static and dynamic traffic assignments consist of demand, network, and route choice model components that need to be calibrated. These components interact with each other, and an iterative method for calibrating them is needed. In this study, an effective standalone framework that combines static demand estimation and dynamic traffic assignment has been developed to replicate real-world traffic conditions. ^ With advances in traffic surveillance technologies collecting, archiving, and analyzing traffic data is becoming more accessible and affordable. The present study shows how data from multiple sources can be integrated, validated, and best used in different stages of modeling and calibration of managed lanes. Extensive and careful processing of demand, traffic, and toll data, as well as proper definition of performance measures, result in a calibrated and stable model, which closely replicates real-world congestion patterns, and can reasonably respond to perturbations in network and demand properties.^

The Mathematics Anxiety of Bilingual Community College Students

Math anxiety levels and performance outcomes were compared for bilingual and monolingual community college Intermediate Algebra students attending a culturally diverse urban commuter college. Participants (N = 618, 250 men, 368 women; 361 monolingual, 257 bilingual) completed the Abbreviated Math Anxiety Scale (AMAS) and a demographics instrument. Bilingual and monolingual students reported comparable mean AMAS scores (20.6 and 20.7, respectively) and comparable proportions of math anxious individuals (50% and 48%, respectively). Factor analysis of AMAS scores, using principal component analysis by varimax rotation, yielded similar two-factor structures for both populations -- assessment and learning content -- accounting for 65.6% of the trace for bilingual AMAS scores. Statistically significant predictor variables for levels of math anxiety for the bilingual participants included (a) preparatory course enrollment (β = .236, p = .041) with those enrolled in prior preparatory courses scoring higher, (b) education major (β = .285, p = .018) with education majors scoring higher, and (c) business major (β = .252, p = .032) with business majors scoring higher. One statistically significant predictor variable emerged for monolingual students, gender (β = -.085, p = .001) with females ranking higher. Age, income, race, ethnicity, U.S. origin, science or health science majors did not emerge as statistically significant predictor variables for either group. Similarities between monolingual and bilingual participants included statistically significant negative linear correlations between AMAS scores and course grades for both bilingual (r = -.178, p = .017) and monolingual participants (r = -.203, p = .001). Differences included a statistically significant linear correlation between AMAS scores and final exam grades for monolingual participants only (r = -.253, p < .0009) despite no statistically significant difference in the strength the linear relationship of the AMAS scores and the final exam scores between groups, z = 1.35, p = .1756. The findings show that bilingual and monolingual students report math anxiety similarly and that math anxiety has similar associations with performance measures, despite differences between predictor variables. One of the first studies on the math anxiety of bilingual community college students, the results suggest recommendations for researchers and practitioners.