The effect of implementing a modified early warning scoring (MEWS) system on the adequacy of vital sign documentation

Introduction and objectives Early recognition of deteriorating patients results in better patient outcomes. Modified early warning scores (MEWS) attempt to identify deteriorating patients early so timely interventions can occur thus reducing serious adverse events. We compared frequencies of vital sign recording 24 h post-ICU discharge and 24 h preceding unplanned ICU admission before and after a new observation chart using MEWS and an associated educational programme was implemented into an Australian Tertiary referral hospital in Brisbane. Design Prospective before-and-after intervention study, using a convenience sample of ICU patients who have been discharged to the hospital wards, and in patients with an unplanned ICU admission, during November 2009 (before implementation; n = 69) and February 2010 (after implementation; n = 70). Main outcome measures Any change in a full set or individual vital sign frequency before-and-after the new MEWS observation chart and associated education programme was implemented. A full set of vital signs included Blood pressure (BP), heart rate (HR), temperature (T°), oxygen saturation (SaO2) respiratory rate (RR) and urine output (UO). Results After the MEWS observation chart implementation, we identified a statistically significant increase (210%) in overall frequency of full vital sign set documentation during the first 24 h post-ICU discharge (95% CI 148, 288%, p value <0.001). Frequency of all individual vital sign recordings increased after the MEWS observation chart was implemented. In particular, T° recordings increased by 26% (95% CI 8, 46%, p value = 0.003). An increased frequency of full vital sign set recordings for unplanned ICU admissions were found (44%, 95% CI 2, 102%, p value = 0.035). The only statistically significant improvement in individual vital sign recordings was urine output, demonstrating a 27% increase (95% CI 3, 57%, p value = 0.029). Conclusions The implementation of a new MEWS observation chart plus a supporting educational programme was associated with statistically significant increases in frequency of combined and individual vital sign set recordings during the first 24 h post-ICU discharge. There were no significant changes to frequency of individual vital sign recordings in unplanned admissions to ICU after the MEWS observation chart was implemented, except for urine output. Overall increases in the frequency of full vital sign sets were seen.

Photocatalytic reduction of carbon dioxide to formic acid, formaldehyde, and methanol using dye-sensitized TiO2 film

A bifunctionalized TiO2 film containing a dye-sensitized zone and a catalysis zone is designed for visible-light photocatalytic reduction of CO2 to chemicals continuously. Charge separation can be accomplished with electron transferring to catalysis zone and positive charge transforming to anode. Highly efficient conversion of CO2 to formic acid, formaldehyde, and methanol is achieved through the transferring electrons on conduction bands (CB) of TiO2. Reduction of CO2 and O2 evolution take place in separated solutions on different catalysts. The separated solution carried out in this photo-reactor system can avoid CO2 reduction products being oxidized by anode. The yields of reduction products were enhanced remarkably by external electrical power. This study provides not only a new photocatalytic system but also a potential of renewable energy source via carbon dioxide.

Delineating the practice profile of advanced practice nursing : a cross-sectional survey using the modified strong model of advanced practice

AIMS: To test a model that delineates advanced practice nursing from the practice profile of other nursing roles and titles. BACKGROUND: There is extensive literature on advanced practice reporting the importance of this level of nursing to contemporary health service and patient outcomes. Literature also reports confusion and ambiguity associated with advanced practice nursing. Several countries have regulation and delineation for the nurse practitioner, but there is less clarity in definition and service focus of other advanced practice nursing roles. DESIGN: A statewide survey. METHODS: Using the modified Strong Model of Advanced Practice Role Delineation tool, a survey was conducted in 2009 with a random sample of registered nurses/midwives from government facilities in Queensland, Australia. Analysis of variance compared total and subscale scores across groups according to grade. Linear, stepwise multiple regression analysis examined factors influencing advanced practice nursing activities across all domains. RESULTS: There were important differences according to grade in mean scores for total activities in all domains of advanced practice nursing. Nurses working in advanced practice roles (excluding nurse practitioners) performed more activities across most advanced practice domains. Regression analysis indicated that working in clinical advanced practice nursing roles with higher levels of education were strong predictors of advanced practice activities overall. CONCLUSION: Essential and appropriate use of advanced practice nurses requires clarity in defining roles and practice levels. This research delineated nursing work according to grade and level of practice, further validating the tool for the Queensland context and providing operational information for assigning innovative nursing service.

Value added products from modified kaolins : new chemical routes to new markets

Chemical treatments of kaolins to produce nanocrystalline or "X-ray amorphous", stable aluminosilicates with variable - but reproducible - types of micro- and meso-porosity have been developed. These materials show cation exchange capacities and surface area values significantly higher (ranging from 10x to 100x) than kaolin and show good acid resistance to pH~3.0. The combination of these properties offers strong potential for many new applications of kaolin-derived materials in large worldwide markets such as environmental remediation and catalysis. Kaolin amorphous derivative (KAD) is well-suited to removal of many toxic metals down to ppb range from acid mine drainage. Engineering development trials of the KAD manufacturing process and the utilisation of KAD in polluted waters such as acid mine drainage indicates that scale-up from bench-scale is not a barrier to market entry.

ECMO : the clinician’s view

Background: Extra corporeal membrane oxygenation (ECMO) is a complex rescue therapy used to provide cardiac and/or respiratory support for critically ill patients who have failed maximal conventional medical management. ECMO is based on a modified cardiopulmonary bypass (CPB) circuit, and can provide cardiopulmonary support for up-to several months. It can be used in a veno venous configuration for isolated respiratory failure, (VV-ECMO), or in a veno arterial configuration (VA-ECMO) where support is necessary for cardiac +/- respiratory failure. The ECMO circuit consists of five main components: large bore cannulae (access cannulae) for drainage of the venous system, and return cannulae to either the venous (in VV-ECMO) or arterial (in VA ECMO) system. An oxygenator, with a vast surface area of hollow filaments, allows addition of oxygen and removal of carbon dioxide; a centrifugal blood pump allows propulsion of blood through the circuit at upto 10 L/minute; a control module and a thermoregulatory unit, which allows for exact temperature control of the extra corporeal blood. Methods: The first successful use of ECMO for ARDS in adults occurred in 1972, and its use has become more commonplace over the last 30 years, supported by the improvement in design and biocompatibility of the equipment, which has reduced the morbidity associated with this modality. Whilst the use of ECMO in neonatal population has been supported by numerous studies, the evidence upon which ECMO was integrated into adult practice was substantially less robust. Results: Recent data, including the CESAR study (Conventional Ventilatory Support versus Extra corporeal membrane oxygenation for Severe Respiratory failure) has added a degree of evidence to the role of ECMO in such a patient population. The CESAR study analysed 180 patients, and confirmed that ECMO was associated with an improved rate of survival. More recently, ECMO has been utilized in numerous situations within the critical care area, including support in high-risk percutaneous interventions in cardiac catheter lab; the operating room, emergency department, as well in specialized inter-hospital retrieval services. The increased understanding of the risk:benefit profile of ECMO, along with a reduction in morbidity associated with its use will doubtless lead to a substantial rise in the utilisation of this modality. As with all extra-corporeal circuits, ECMO opposes the basic premises of the mammalian inflammation and coagulation cascade where blood comes into foreign circulation, both these cascades are activated. Anti-coagulation is readily dealt with through use of agents such as heparin, but the inflammatory excess, whilst less macroscopically obvious, continues un-abated. Platelet consumption and neutrophil activation occur rapidly, and the clinician is faced with balancing the need of anticoagulation for the circuit, against haemostasis in an acutely bleeding patient. Alterations in pharmacokinetics may result in inadequate levels of disease modifying therapeutics, such as antibiotics, hence paradoxically delaying recovery from conditions such as pneumonia. Key elements of nutrition and the innate immune system maysimilarly be affected. Summary: This presentation will discuss the basic features of ECMO to the nonspecialist, and review the clinical conundrum faced by the team treating these most complex cases.

Modified kaolins

A process for the preparation of a modified kaolin from a kaolin group mineral which includes expansion and contraction of layers of the kaolin group mineral. The layers comprising one Si-tetrahedral sheet and one Al-octahedral sheet. The expansion and contraction may be initiated by initial intercalation of a reagent which can penetrate kaolin layers to reach an interlayer region there between to form an intercalate. Subsequently, the intercalation may be followed by de-intercalation which involves the removal of the reagent. By the above process, there is provided crystalline modified kaolins having the following properties: (i) an increased interlayer space compared to corresponding kaolin group minerals; (ii) an increased susceptibility to intercalation by cations, anions or salts compared to corresponding kaolin group minerals; and (iii) an increased exfoliated morphology compared to corresponding kaolin group minerals.

Advanced practice nursing role development : factor analysis of a modified role delineation tool

Aim his study reports the use of exploratory factor analysis to determine construct validity of a modified advanced practice role delineation tool. Background Little research exists on specific activities and domains of practice within advanced practice nursing roles, making it difficult to define service parameters of this level of nursing practice. A valid and reliable tool would assist those responsible for employing or deploying advanced practice nurses by identifying and defining their service profile. This is the third paper from a multi-phase Australian study aimed at assigning advanced practice roles. Methods A postal survey was conducted of a random sample of state government employed Registered nurses and midwives, across various levels and grades of practice in the state of Queensland, Australia, using the modified Advanced Practice Role Delineation tool. Exploratory factor analysis, using principal axis factoring was undertaken to examine factors in the modified tool. Cronbach’s alpha coefficient determined reliability of the overall scale and identified factors. Results There were 658 responses (42% response rate). The five factors found with loadings of ≥.400 for 40 of the 41 APN activities were similar to the five domains in the Strong model. Cronbach’s alpha coefficient was .94 overall and for the factors ranged from 0.83 to 0.95. Conclusion Exploratory factor analysis of the modified tool supports validity of the five domains of the original tool. Further investigation will identify use of the tool in a broader healthcare environment.

Challenges facing carbon dioxide labelling of construction materials

In the absence of a benchmarking mechanism specifically designed for local requirements and characteristics, a carbon dioxide footprint assessment and labelling scheme for construction materials is urgently needed to promote carbon dioxide reduction in the construction industry. This paper reports on a recent interview survey of 18 senior industry practitioners in Hong Kong to elicit their knowledge and opinions concerning the potential of such a carbon dioxide labelling scheme. The results of this research indicate the following. A well-designed carbon dioxide label could stimulate demand for low carbon dioxide construction materials. The assessment of carbon dioxide emissions should be extended to different stages of material lifecycles. The benchmarks for low carbon dioxide construction materials should be based on international standards but without sacrificing local integrity. Administration and monitoring of the carbon dioxide labelling scheme could be entrusted to an impartial and independent certification body. The implementation of any carbon dioxide labelling schemes should be on a voluntary basis. Cost, functionality, quality and durability are unlikely to be replaced by environmental considerations in the absence of any compelling incentives or penalties. There are difficulties in developing and operating a suitable scheme, particularly in view of the large data demands involved, reluctance in using low carbon dioxide materials and limited environmental awareness.

The cost of carbon : capital market effects of the proposed emission trading scheme (ETS)

In March 2008, the Australian Government announced its intention to introduce a national Emissions Trading Scheme (ETS), now expected to start in 2015. This impending development provides an ideal setting to investigate the impact an ETS in Australia will have on the market valuation of Australian Securities Exchange (ASX) firms. This is the first empirical study into the pricing effects of the ETS in Australia. Primarily, we hypothesize that firm value will be negatively related to a firm's carbon intensity profile. That is, there will be a greater impact on firm value for high carbon emitters in the period prior (2007) to the introduction of the ETS, whether for reasons relating to the existence of unbooked liabilities associated with future compliance and/or abatement costs, or for reasons relating to reduced future earnings. Using a sample of 58 Australian listed firms (constrained by the current availability of emissions data) which comprise larger, more profitable and less risky listed Australian firms, we first undertake an event study focusing on five distinct information events argued to impact the probability of the proposed ETS being enacted. Here, we find direct evidence that the capital market is indeed pricing the proposed ETS. Second, using a modified version of the Ohlson (1995) valuation model, we undertake a valuation analysis designed not only to complement the event study results, but more importantly to provide insights into the capital market's assessment of the magnitude of the economic impact of the proposed ETS as reflected in market capitalization. Here, our results show that the market assesses the most carbon intensive sample firms a market value decrement relative to other sample firms of between 7% and 10% of market capitalization. Further, based on the carbon emission profile of the sample firms we imply a ‘future carbon permit price’ of between AUD$17 per tonne and AUD$26 per tonne of carbon dioxide emitted. This study is more precise than industry reports, which set a carbon price of between AUD$15 to AUD$74 per tonne.

Recent advances in catalytic/biocatalytic conversion of greenhouse methane and carbon dioxide to methanol and other oxygenates

Methane gas has been identified as the most destructive greenhouse gas (Liu et al., 2004). It was reported that the global warming potential of methane per molecule relative to CO2 is approximately 23 on a 100-year timescale or 62 over a 20-year period (IPCC, 2001). Methane has high C-H bond energy of about 439 kJ/mol and other higher alkanes (or saturated hydrocarbons) also have a very strong C-C and C-H bonds, thus making their molecules to have no empty orbitals of low energy or filled orbitals of high energy that could readily participate in chemical reactions as is the case with unsaturated hydrocarbons such as olefins and alkynes (Crabtree, 1994; Labinger & Bercaw, 2002)...

Non-Newtonian natural convection flow along an isothermal horizontal circular cylinder using modified power-law model

Laminar two-dimensional natural convection boundary-layer flow of non-Newtonian fluids along an isothermal horizontal circular cylinder has been studied using a modified power-law viscosity model. In this model, there are no unrealistic limits of zero or infinite viscosity. Therefore, the boundary-layer equations can be solved numerically by using marching order implicit finite difference method with double sweep technique. Numerical results are presented for the case of shear-thinning as well as shear thickening fluids in terms of the fluid velocity and temperature distributions, shear stresses and rate of heat transfer in terms of the local skin-friction and local Nusselt number respectively.

Increasing NH4+ retention efficiency of sandy soils by adding a modified kaolin material: Mesolite

Water and ammonium retention by sandy soils may be low and result in leaching of applied fertiliser. To increase water and nutrient retention, zeolite is sometimes applied as a soil ameliorant for high value land uses including turf and horticulture. We have used a new modified kaolin material (MesoLite) as a soil amendment to test the efficiency of NH4+ retention and compared the results with natural zeolite. MesoLite is made by caustic reaction of kaolin at temperature between 80-95°C; although it has a moderate surface area, its cation exchange capacity is very high;(SA=13m2/g,CEC=500meq/100g). A 13cm tall sand column filled with ~450g of sandy soil homogeneously mixed with 1, 2, 4, and 8g of MesoLite or natural zeolite per 1kg of soil was prepared. After saturation with local bore water, concentrated ammonium sulfate solution was injected at the base. Then, bore water was passed from bottom to top through the column at amounts up to 6 pore volumes and at a constant flow rate of 10ml/min using a peristaltic pump. Concentrations of leached NH4+ were determined using an AutoAnalyser. The concentration of NH4+ leached from the column with 0.4% MesoLite was greatly (90%) reduced relative to unamended soil. Under these conditions NH4+ retention by the soil-MesoLite mixture was 11.5 times more efficient than the equivalent soil-natural zeolite mixture. Glasshouse experiments conducted in a separate study show that NH4+ adsorbed by MesoLite is available to plants.