Demand for public hospital emergency department services in Australia : 2000–2001 to 2009–2010

Objective: Hospital EDs are a significant and high-profile component of Australia’s health-care system, which in recent years have experienced considerable crowding. This crowding is caused by the combination of increasing demand, throughput and output factors. The aim of the present article is to clarify trends in the use of public ED services across Australia with a view to providing an evidence basis for future policy analysis and discussion. Methods: The data for the present article have been extracted, compiled and analysed from publicly available sources for a 10 year period between 2000–2001 and 2009–2010. Results: Demand for public ED care increased by 37% over the decade, an average annual increase of 1.8% in the utilization rate per 1000 persons. There were significant differences in utilization rates and in trends in growth among states and territories that do not easily relate to general population trends alone. Conclusions: This growth in demand exceeds general population growth, and the variability between states both in utilization rates and overall trends defies immediate explanation. The growth in demand for ED services is a partial contributor to the crowding being experienced in EDs across Australia. There is a need for more detailed study, including qualitative analysis of patient motivations in order to identify the factors driving this growth in demand.

Fundamentals of process integration

Technologies and languages for integrated processes are a relatively recent innovation. Over that period many divergent waves of innovation have transformed process integration. Like sockets and distributed objects, early workflow systems ordered programming interfaces that connected the process modelling layer to any middleware. BPM systems emerged later, connecting the modelling world to middleware through components. While BPM systems increased ease of use (modelling convenience), long-standing and complex interactions involving many process instances remained di±cult to model. Enterprise Service Buses (ESBs), followed, connecting process models to heterogeneous forms of middleware. ESBs, however, generally forced modellers to choose a particular underlying middleware and to stick to it, despite their ability to connect with many forms of middleware. Furthermore ESBs encourage process integrations to be modelled on their own, logically separate from the process model. This can lead to the inability to reason about long standing conversations at the process layer. Technologies and languages for process integration generally lack formality. This has led to arbitrariness in the underlying language building blocks. Conceptual holes exist in a range of technologies and languages for process integration and this can lead to customer dissatisfaction and failure to bring integration projects to reach their potential. Standards for process integration share similar fundamental flaws to languages and technologies. Standards are also in direct competition with other standards causing a lack of clarity. Thus the area of greatest risk in a BPM project remains process integration, despite major advancements in the technology base. This research examines some fundamental aspects of communication middleware and how these fundamental building blocks of integration can be brought to the process modelling layer in a technology agnostic manner. This way process modelling can be conceptually complete without becoming stuck in a particular middleware technology. Coloured Petri nets are used to define a formal semantics for the fundamental aspects of communication middleware. They provide the means to define and model the dynamic aspects of various integration middleware. Process integration patterns are used as a tool to codify common problems to be solved. Object Role Modelling is a formal modelling technique that was used to define the syntax of a proposed process integration language. This thesis provides several contributions to the field of process integration. It proposes a framework defining the key notions of integration middleware. This framework provides a conceptual foundation upon which a process integration language could be built. The thesis defines an architecture that allows various forms of middleware to be aggregated and reasoned about at the process layer. This thesis provides a comprehensive set of process integration patterns. These constitute a benchmark for the kinds of problems a process integration language must support. The thesis proposes a process integration modelling language and a partial implementation that is able to enact the language. A process integration pilot project in a German hospital is brie°y described at the end of the thesis. The pilot is based on ideas in this thesis.

Demand for hospital emergency departments : a conceptual understanding

BACKGROUND: Emergency departments (EDs) are critical to the management of acute illness and injury, and the provision of health system access. However, EDs have become increasingly congested due to increased demand, increased complexity of care and blocked access to ongoing care (access block). Congestion has clinical and organisational implications. This paper aims to describe the factors that appear to infl uence demand for ED services, and their interrelationships as the basis for further research into the role of private hospital EDs. DATA SOURCES: Multiple databases (PubMed, ProQuest, Academic Search Elite and Science Direct) and relevant journals were searched using terms related to EDs and emergency health needs. Literature pertaining to emergency department utilisation worldwide was identified, and articles selected for further examination on the basis of their relevance and significance to ED demand. RESULTS: Factors influencing ED demand can be categorized into those describing the health needs of the patients, those predisposing a patient to seeking help, and those relating to policy factors such as provision of services and insurance status. This paper describes the factors influencing ED presentations, and proposes a novel conceptual map of their interrelationship. CONCLUSION: This review has explored the factors contributing to the growing demand for ED care, the influence these factors have on ED demand, and their interrelationships depicted in the conceptual model.

The influence of architecture on degradation and tissue ingrowth into three-dimensional poly(lactic-co-glycolic acid) scaffolds in vitro and in vivo

The in vitro and in vivo degradation properties of poly(lactic-co-glycolic acid) (PLGA) scaffolds produced by two different technologies - thermally induced phase separation (TIPS), and solvent casting and particulate leaching (SCPL) were compared. Over 6 weeks, in vitro degradation produced changes in SCPL scaffold dimension, mass, internal architecture and mechanical properties. TIPS scaffolds produced far less changes in these parameters providing significant advantages over SCPL. In vivo results were based on a microsurgically created arteriovenous (AV) loop sandwiched between two TIPS scaffolds placed in a polycarbonate chamber under rat groin skin. Histologically, a predominant foreign body giant cell response and reduced vascularity was evident in tissue ingrowth between 2 and 8 weeks in TIPS scaffolds. Tissue death occurred at 8 weeks in the smallest pores. Morphometric comparison of TIPS and SCPL scaffolds indicated slightly better tissue ingrowth but greater loss of scaffold structure in SCPL scaffolds. Although advantageous in vitro, large surface area:volume ratios and varying pore sizes in PLGA TIPS scaffolds mean that effective in vivo (AV loop) utilization will only be achieved if the foreign body response can be significantly reduced so as to allow successful vascularisation, and hence sustained tissue growth, in pores less than 300 μm. © 2005 Elsevier Ltd. All rights reserved.

Effects of wearing a pressure redistribution belt while lying in a hospital bed

Bedsores (ulcers) are caused by multiple factors which include, but are not limited to; pressure, shear force, friction, temperature, age and medication. Specialised support services, such as specialised mattresses, sheepskin coverings etc., are thought to decrease or relieve pressure, resulting in a lowering of pressure ulcer incidence [3]. The primary aim of this study was to compare the upper/central body pressure distribution between normal lying in a hospital bed versus the use of a pressure redistribution belt. The study involved 16 healthy voluntary subjects lying on a hospital bed with and without wearing the belt. Results showed that the use of a pressure redistribution belt results in reduced pressure peaks and prevents the pressure from increasing over time.

Effectiveness of powered hospital bed movers for reducing physiological strain and back muscle activation

Battery powered bed movers are becoming increasingly common within the hospital setting. The use of powered bed movers is believed to result in reduced physical efforts required by health care workers, which may be associated with a decreased risk of occupation related injuries. However, little work has been conducted assessing how powered bed movers impact on levels of physiological strain and muscle activation for the user. The muscular efforts associated with moving hospital beds using three different methods; manual pushing, StaminaLift Bed Mover (SBM) and Gzunda Bed Mover (GBM)were measured on six male subjects. Fourteen muscles were assessed moving a weighted hospital bed along a standardized route in an Australian hospital environment. Trunk inclination and upper spine acceleration were also quantified. Powered bed movers exhibited significantly lower muscle activation levels than manual pushing for the majority of muscles. When using the SBM, users adopted a more upright posture which was maintained while performing different tasks (e.g. turning a corner, entering a lift), while trunk inclination varied considerably for manual pushing and the GBM. The reduction in lower back muscular activation levels and the load reducing effect of a more upright posture may result in lower incidence of lower back injury.

Prevalence of malnutrition risk and its relationship with risk factors of hospital re-admission in older adults

Background: Risk of malnutrition in older people continues to be a global problem. Malnutrition is often unrecognized and under-treated across health care settings and may result in undesirable health consequences, impaired recovery from illness and a poorer quality of life. Aim: This study aimed to determine the prevalence of malnutrition risk in a sample of older people at high risk of hospital re-admission. The association between risk factors of hospital re-admission and risk of malnutrition were also explored. Methods: One hundred and twenty five hospitalised patients aged 65 years and older at risk of hospital readmission (24% male, 76% female, mean age 77 ± 6 years) were recruited from a tertiary metropolitan hospital in Australia. The valid and reliable Malnutrition Screen Tool (MST) was employed to screen for malnutrition risk. It consists of two questions related to recent weight loss and appetite. Results: Prevalence of older adults at risk of malnutrition was 27.4%. Risk of malnutrition was not associated with age, gender and living arrangement. However, among risk factors of hospital readmission, lack of social support (χ2 = 4.18, N = 125, p = 0.028), and fair –poor self-rating of health (χ2 = 4.13, N = 125, p = 0.042) were statistically significant associated with risk of malnutrition. Conclusion: Risk of malnutrition in older people continues to be a concern in health care, and increasing psycho social support may help shed light on reducing risk of malnutrition.

Validity of the malnutrition screening tool for older adults at high risk of hospital readmission

Malnutrition is a serious problem in older adults, particularly for those at risk of hospital readmission. The essential step in managing malnutrition is early identification using a valid nutrition screening tool. The purpose of this study was to validate the Malnutrition Screening Tool (MST) in older adults at high risk of hospital readmission. Two registered nurses administered the MST to identify malnutrition risk, and compared it to the comprehensive Subjective Global Assessment (SGA) to assess nutritional status for patients aged 65 years who had at least one risk factor for hospital readmission. The MST demonstrates substantial sensitivity, specificity and agreement with the SGA. These findings indicate that nursing staff can use the MST as a valid tool for routine screening and rescreening to identify patients at risk of malnutrition. Use of the MST may prevent hospital-acquired malnutrition for acute hospitalized older adults at high risk of readmission.

Place and displacement : southeast Queensland architecture

The "vernacular" housing tradition of southeast Queensland is easily identifiable. Its history is more complex. This study seeks to challenge two popular conceptions of the "Queenslander" history by showing that they actually provide contradictory explanations. The aim is to produce a more complex account of local architecture and its historical explanation so that both its past and its present practices can be better understood as a distinctly subtropical idiom. This discussion shows that such practices may respond to common concerns but that are also ever-changing.

Entertainment architecture : constructing a framework for the creation of an emerging transmedia form

This thesis investigates the radically uncertain formal, business, and industrial environment of current entertainment creators. It researches how a novel communication technology, the Internet, leads to novel entertainment forms, how these lead to novel kinds of businesses that lead to novel industries; and in what way established entertainment forms, businesses, and industries are part of that process. This last aspect is addressed by focusing on one exemplary es-tablished form: movies. Using a transdisciplinary approach and a combination of historical analysis, industry interviews, and an innovative mode of ‘immersive’ textual analysis, a coherent and comprehensive conceptual framework for the creation of and re-search into a specific emerging entertainment form is proposed. That form, products based on it, and the conceptual framework describing it are all re-ferred to as Entertainment Architecture (‘entarch,’ for short). The thesis charac-terises this novel form as Internet-native transmedia entertainment, meaning it fully utilises the unique communicative characteristics of the Internet, and is spread across media. The thesis isolates four constitutive elements within Entertainment Architec-ture: story, play, ‘dance,’ and ‘glue.’ That is, entarch tells a story; offers playful interaction; invites social interaction between producer and consumer, and amongst consumers (‘dance’); and all components of it can be spread across many media, but are so well interconnected and mutually dependent that they are perceived as one product instead of many (‘glue’). This sets entarch apart from current media franchises like Star Wars or Halo, which are perceived as many products spread across many media. Entarch thus embraces the commu-nicative behaviour of Internet-native consumers instead of forcing them to de-sist from it, it harnesses the strengths of various media while avoiding some of their weaknesses, and it can sustain viable businesses. The entarch framework is an innovative contribution to scholarship that al-lows researchers to investigate this emerging entertainment form in a structured way. The thesis demonstrates this by using it to survey business models appro-priate to the entarch environment. The framework can also be used by enter-tainment creators — exemplified in the thesis by moviemakers — to delimit the room for manoeuvre available to them in a changing environment.

Assessing the effectiveness of the child safety net : linkage of hospital and child protection services data on ‘maltreated’ and ‘unintentionally injured' children

-International recognition of need for public health response to child maltreatment -Need for early intervention at health system level -Important role of health professionals in identifying, reporting, documenting suspician of maltreatment -Up to 10% of all children presenting at ED’s are victims and without identification, 35% reinjured and 5% die -In Qld, mandatory reporting requirement for doctors and nurses for suspected abuse or neglect

Measuring the realization of benefits from enterprise architecture management

Enterprise architecture management (EAM) has become an intensively discussed approach to manage enterprise transformations. While many organizations employ EAM, a notable insecurity about the value of EAM remains. In this paper, we propose a model to measure the realization of benefits from EAM. We identify EAM success factors and EAM benefits through a comprehensive literature review and eleven explorative expert interviews. Based on our findings, we integrate the EAM success factors and benefits with the established DeLone & McLean IS success model resulting in a model that explains the realization of EAM benefits. This model aids organizations as a benchmark and framework for identifying and assessing the setup of their EAM initiatives and whether and how EAM benefits are materialized. We see our model also as a first step to gain insights in and start a discussion on the theory of EAM benefit realization.

Realizing benefits from enterprise architecture : a measurement model

Enterprise architecture (EA) management has become an intensively discussed approach to manage enterprise transformations. Despite the popularity and potential of EA, both researchers and practitioners lament a lack of knowledge about the realization of benefits from EA. To determine the benefits from EA, we explore the various dimensions of EA benefit realization and report on the development of a validated and robust measurement instrument. In this paper, we test the reliability and construct validity of the EA benefit realization model (EABRM), which we have designed based on the DeLone & McLean IS success model and findings from exploratory interviews. A confirmatory factor analysis confirms the existence of an impact of five distinct and individually important dimensions on the benefits derived from EA: EA artefact quality, EA infrastructure quality, EA service quality, EA culture, and EA use. The analysis presented in this paper shows that the EA benefit realization model is an instrument that demonstrates strong reliability and validity.

Porous scaffold architecture guides tissue formation

Critical-sized bone defect regeneration is a remaining clinical concern. Numerous scaffold-based strategies are currently being investigated to enable in vivo bone defect healing. However, a deeper understanding of how a scaffold influences the tissue formation process and how this compares to endogenous bone formation or to regular fracture healing is missing. It is hypothesized that the porous scaffold architecture can serve as a guiding substrate to enable the formation of a structured fibrous network as a prerequirement for later bone formation. An ovine, tibial, 30-mm critical-sized defect is used as a model system to better understand the effect of the scaffold architecture on cell organization, fibrous tissue, and mineralized tissue formation mechanisms in vivo. Tissue regeneration patterns within two geometrically distinct macroscopic regions of a specific scaffold design, the scaffold wall and the endosteal cavity, are compared with tissue formation in an empty defect (negative control) and with cortical bone (positive control). Histology, backscattered electron imaging, scanning small-angle X-ray scattering, and nanoindentation are used to assess the morphology of fibrous and mineralized tissue, to measure the average mineral particle thickness and the degree of alignment, and to map the local elastic indentation modulus. The scaffold proves to function as a guiding substrate to the tissue formation process. It enables the arrangement of a structured fibrous tissue across the entire defect, which acts as a secondary supporting network for cells. Mineralization can then initiate along the fibrous network, resulting in bone ingrowth into a critical-sized defect, although not in complete bridging of the defect. The fibrous network morphology, which in turn is guided by the scaffold architecture, influences the microstructure of the newly formed bone. These results allow a deeper understanding of the mode of mineral tissue formation and the way this is influenced by the scaffold architecture. Copyright © 2012 American Society for Bone and Mineral Research.

The relationship between chronic disease self-efficacy and nutritional status, functional ability and quality of life in older adults at risk of hospital readmission

Background and significance: Older adults with chronic diseases are at increasing risk of hospital admission and readmission. Approximately 75% of adults have at least one chronic condition, and the odds of developing a chronic condition increases with age. Chronic diseases consume about 70% of the total Australian health expenditure, and about 59% of hospital events for chronic conditions are potentially preventable. These figures have brought to light the importance of the management of chronic disease among the growing older population. Many studies have endeavoured to develop effective chronic disease management programs by applying social cognitive theory. However, limited studies have focused on chronic disease self-management in older adults at high risk of hospital readmission. Moreover, although the majority of studies have covered wide and valuable outcome measures, there is scant evidence on examining the fundamental health outcomes such as nutritional status, functional status and health-related quality of life. Aim: The aim of this research was to test social cognitive theory in relation to self-efficacy in managing chronic disease and three health outcomes, namely nutritional status, functional status, and health-related quality of life, in older adults at high risk of hospital readmission. Methods: A cross-sectional study design was employed for this research. Three studies were undertaken. Study One examined the nutritional status and validation of a nutritional screening tool; Study Two explored the relationships between participants. characteristics, self-efficacy beliefs, and health outcomes based on the study.s hypothesized model; Study Three tested a theoretical model based on social cognitive theory, which examines potential mechanisms of the mediation effects of social support and self-efficacy beliefs. One hundred and fifty-seven patients aged 65 years and older with a medical admission and at least one risk factor for readmission were recruited. Data were collected from medical records on demographics, medical history, and from self-report questionnaires. The nutrition data were collected by two registered nurses. For Study One, a contingency table and the kappa statistic was used to determine the validity of the Malnutrition Screening Tool. In Study Two, standard multiple regression, hierarchical multiple regression and logistic regression were undertaken to determine the significant influential predictors for the three health outcome measures. For Study Three, a structural equation modelling approach was taken to test the hypothesized self-efficacy model. Results: The findings of Study One suggested that a high prevalence of malnutrition continues to be a concern in older adults as the prevalence of malnutrition was 20.6% according to the Subjective Global Assessment. Additionally, the findings confirmed that the Malnutrition Screening Tool is a valid nutritional screening tool for hospitalized older adults at risk of readmission when compared to the Subjective Global Assessment with high sensitivity (94%), and specificity (89%) and substantial agreement between these two methods (k = .74, p < .001; 95% CI .62-.86). Analysis data for Study Two found that depressive symptoms and perceived social support were the two strongest influential factors for self-efficacy in managing chronic disease in a hierarchical multiple regression. Results of multivariable regression models suggested advancing age, depressive symptoms and less tangible support were three important predictors for malnutrition. In terms of functional status, a standard regression model found that social support was the strongest predictor for the Instrumental Activities of Daily Living, followed by self-efficacy in managing chronic disease. The results of standard multiple regression revealed that the number of hospital readmission risk factors adversely affected the physical component score, while depressive symptoms and self-efficacy beliefs were two significant predictors for the mental component score. In Study Three, the results of the structural equation modelling found that self-efficacy partially mediated the effect of health characteristics and depression on health-related quality of life. The health characteristics had strong direct effects on functional status and body mass index. The results also indicated that social support partially mediated the relationship between health characteristics and functional status. With regard to the joint effects of social support and self-efficacy, social support fully mediated the effect of health characteristics on self-efficacy, and self-efficacy partially mediated the effect of social support on functional status and health-related quality of life. The results also demonstrated that the models fitted the data well with relative high variance explained by the models, implying the hypothesized constructs under discussion were highly relevant, and hence the application for social cognitive theory in this context was supported. Conclusion: This thesis highlights the applicability of social cognitive theory on chronic disease self-management in older adults at risk of hospital readmission. Further studies are recommended to validate and continue to extend the development of social cognitive theory on chronic disease self-management in older adults to improve their nutritional and functional status, and health-related quality of life.