Practice and perception--a nationwide survey of therapy habits in sepsis

OBJECTIVE: To simultaneously determine perceived vs. practiced adherence to recommended interventions for the treatment of severe sepsis or septic shock. DESIGN: One-day cross-sectional survey. SETTING: Representative sample of German intensive care units stratified by hospital size. PATIENTS: Adult patients with severe sepsis or septic shock. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Practice recommendations were selected by German Sepsis Competence Network (SepNet) investigators. External intensivists visited intensive care units randomly chosen and asked the responsible intensive care unit director how often these recommendations were used. Responses "always" and "frequently" were combined to depict perceived adherence. Thereafter patient files were audited. Three hundred sixty-six patients on 214 intensive care units fulfilled the criteria and received full support. One hundred fifty-two patients had acute lung injury or acute respiratory distress syndrome. Low-tidal volume ventilation < or = 6 mL/kg/predicted body weight was documented in 2.6% of these patients. A total of 17.1% patients had tidal volume between 6 and 8 mL/kg predicted body weight and 80.3% > 8 mL/kg predicted body weight. Mean tidal volume was 10.0 +/- 2.4 mL/kg predicted body weight. Perceived adherence to low-tidal volume ventilation was 79.9%. Euglycemia (4.4-6.1 mmol/L) was documented in 6.2% of 355 patients. A total of 33.8% of patients had blood glucose levels < or = 8.3 mmol/L and 66.2% were hyperglycemic (blood glucose > 8.3 mmol/L). Among 207 patients receiving insulin therapy, 1.9% were euglycemic, 20.8% had blood glucose levels < or = 8.3 mmol/L, and 1.0% were hypoglycemic. Overall, mean maximal glucose level was 10.0 +/- 3.6 mmol/L. Perceived adherence to strict glycemic control was 65.9%. Although perceived adherence to recommendations was higher in academic and larger hospitals, actual practice was not significantly influenced by hospital size or university affiliation. CONCLUSIONS: This representative survey shows that current therapy of severe sepsis in German intensive care units complies poorly with practice recommendations. Intensive care unit directors perceive adherence to be higher than it actually is. Implementation strategies involving all intensive care unit staff are needed to overcome this gap between current evidence-based knowledge, practice, and perception.

Cywilnoprawne granice optymalizacji podatkowej w zakresie podatku dochodowego od osób prawnych (analiza struktur planowania podatkowego)

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How single is ‘single’ : some pragmatic reflections on single versus multifaceted interventions to facilitate implementation

An earlier overview of systematic reviews and a subsequent editorial on single-component versus multifaceted interventions to promote knowledge translation (KT) highlight complex issues in implementation science. In this supplemented commentary, further aspects are in focus; we propose examples from (KT) studies probing the issue of single interventions. A main point is that defining what is a single and what is a multifaceted intervention can be ambiguous, depending on how the intervention is conceived. Further, we suggest additional perspectives in terms of strategies to facilitate implementation. More specifically, we argue for a need to depict not only what activities are done in implementation interventions, but to unpack functions in particular contexts, in order to support the progress of implementation science.

The expensive energy revolution in Germany. The implementation of the Energiewende is behind schedule. OSW Commentary No. 77, 2012-05-10

One year after the events of Fukushima the implementation of the new German energy strategy adopted in the summer of 2011 is being verified. Business circles, experts and publicists are sounding the alarm. The tempo at which the German economy is being rearranged in order that it uses renewable energy sources is so that it has turned out to be an extremely difficult and expensive task. The implementation of the key guidelines of the new strategy, such as the development of the transmission networks and the construction of new conventional power plants, is meeting increasing resistance in the form of economic and legal difficulties. The development of the green technologies sector is also posing problems. The solar energy industry, for example, is excessively subsidised, whereas the subsidies for the construction of maritime wind farms are too low. At present, only those guidelines of the strategy which are evaluated as economically feasible by investors or which receive adequate financial support from the state have a chance of being carried through. The strategy may also turn out to be unsuccessful due to the lack of a comprehensive coordination of its implementation and the financial burden its introduction entails for both the public and the economy. In the immediate future, the German government will make efforts not only to revise its internal regulations in order to enable the realisation of the energy transformation; it is also likely to undertake a number of measures at the EU forum which will facilitate this realisation. One should expect that the German government will actively support the financing of both the development of the energy networks in EU member states and the development of renewable energy sources in the energy sector.

"Where is the Wealth?" Echoing the King's 2014 speech in light of the delay in the implementation of the new Constitution. Arab Citizenship Review No. 16, 19 February 2016

In Morocco, the new Constitution promised by King Mohammed VI in 2011 has raised high expectations regarding the improvement of socio-economic standards in the country and the possible redistribution of national wealth in a more transparent and democratic way. Just like Tunisia and Egypt, Moroccan demonstrators of the 20 February Movement had taken to the streets to ask for more freedom and democracy, but also to call for social equality and an end to corruption. Many of the grievances and the claims raised by demonstrators fell within the domain of socio-economic rights. Even though it might still be early to take stock, five years down the road, it is possible to provide a fist assessment of the major changes in Morocco in the socio-economic area. The attempt is to analyse whether the improvements introduced by the new Constitution have met the expectations of the people standing up for their rights in the wake of the Arab Spring, or whether the Kingdom of Morocco has fallen short on its promise to undertake structural change.

The devil is in the detail:tobacco industry political influence in the Dutch implementation of the 2001 EU Tobacco Products Directive

Introduction - The Dutch implementation of the black border provision in the 2001 European Union Tobacco Products Directive (TPD) is studied to examine the implications of tobacco industry involvement in the implementation phase of the policy process. Methods - A qualitative analysis was conducted of Dutch government documents obtained through Freedom of Information Act requests, triangulated with in-depth interviews with key informants and secondary data sources (publicly available government documents, scientific literature, and news articles). Results - Tobacco manufacturers’ associations were given the opportunity to set implementation specifications via a fast-track deal with the government. The offer of early implementation of the labelling section of the TPD was used as political leverage by the industry, and underpinned by threats of litigation and arguments highlighting the risks of additional public costs and the benefits to the government of expediency and speed. Ultimately, the government agreed to the industry's interpretation, against the advice of the European Commission. Conclusions - The findings highlight the policy risks associated with corporate actors’ ability to use interactions over technical product specifications to influence the implementation of health policy and illustrate the difficulties in limiting industry interference in accordance with Article 5.3 of the Framework Convention on Tobacco Control (FCTC). The implementation phase is particularly vulnerable to industry influence, where negotiation with industry actors may be unavoidable and the practical implications of relatively technical considerations are not always apparent to policymakers. During the implementation of the new TPD 2014/40/EU, government officials are advised to take a proactive role in stipulating technical specifications.

It is not that simple nor compelling! Comment on "Translating evidence into healthcare policy and practice: single versus multi-faceted implementation strategies - is there a simple answer to a complex question?"

Healthcare decisions are often made under pressure, with varying levels of information in a changing clinical context. With limited resources and a focus on improving patient outcomes, healthcare managers and health professionals strive to implement both clinical and cost-effective care. However, the gap between research evidence and health policy/clinical practice persists despite our best efforts. In an attempt to close the gap through behaviour change interventions, there has been a strong held belief that 'more is better,' without understanding the mechanisms and circumstances of knowledge translation (KT). We argue that even a single intervention or strategy in translating evidence into healthcare policy or practice is rarely simple to implement. Nor is the evidence compelling on the best approach. As Harvey and Kitson argued, designing and evaluating KT interventions requires flexibility and responsiveness. If we are to move forward in translation science then we need to use rigorous designs such as randomised controlled trials to test effectiveness of interventions or strategies with embedded process evaluations to understand the reason interventions do or do not work!

An investigation into the barriers to the implementation of automation and robotics technologies in the construction industry

The rising problems associated with construction such as decreasing quality and productivity, labour shortages, occupational safety, and inferior working conditions have opened the possibility of more revolutionary solutions within the industry. One prospective option is in the implementation of innovative technologies such as automation and robotics, which has the potential to improve the industry in terms of productivity, safety and quality. The construction work site could, theoretically, be contained in a safer environment, with more efficient execution of the work, greater consistency of the outcome and higher level of control over the production process. By identifying the barriers to construction automation and robotics implementation in construction, and investigating ways in which to overcome them, contributions could be made in terms of better understanding and facilitating, where relevant, greater use of these technologies in the construction industry so as to promote its efficiency. This research aims to ascertain and explain the barriers to construction automation and robotics implementation by exploring and establishing the relationship between characteristics of the construction industry and attributes of existing construction automation and robotics technologies to level of usage and implementation in three selected countries; Japan, Australia and Malaysia. These three countries were chosen as their construction industry characteristics provide contrast in terms of culture, gross domestic product, technology application, organisational structure and labour policies. This research uses a mixed method approach of gathering data, both quantitative and qualitative, by employing a questionnaire survey and an interview schedule; using a wide range of sample from management through to on-site users, working in a range of small (less than AUD0.2million) to large companies (more than AUD500million), and involved in a broad range of business types and construction sectors. Detailed quantitative (statistical) and qualitative (content) data analysis is performed to provide a set of descriptions, relationships, and differences. The statistical tests selected for use include cross-tabulations, bivariate and multivariate analysis for investigating possible relationships between variables; and Kruskal-Wallis and Mann Whitney U test of independent samples for hypothesis testing and inferring the research sample to the construction industry population. Findings and conclusions arising from the research work which include the ranking schemes produced for four key areas of, the construction attributes on level of usage; barrier variables; differing levels of usage between countries; and future trends, have established a number of potential areas that could impact the level of implementation both globally and for individual countries.

Final report implementation of relational management

Construction teams and construction organisations have their own distinctive cultures. There also exists an infrastructure, both social and contractual, which ensures that these projects within which the teams operate are completed successfully. It is these issues which this research has addressed. The project was instigated by Queensland Department of Main Roads, Public Works and John Holland Group in order to address how they might better implement relationship management (RM) on their construction projects. The project was devised initially in order to facilitate a change in culture which would allow the project to be run in a relational manner and would lead to effective performance in terms of the KPIs that the organisations set for themselves, described as business better than usual. This report describes the project, its outcomes and deliverable and indicates the changes that were made to the project during the research process. Hence, the initial premise of the project and the problem to investigate was the implementation of relational contracting: • throughout a range of projects; • with a focus on client body staff. The additions that were made to the project, and documented in the variations to the project, included two major additional areas of study: • client management and stakeholder management; • a live case study of an alliancing project. The context within which the research was undertaken is important. The research was driven by main roads with their desire to improve their operations by focusing on the relationship between the major project participants (however, stakeholder and client organisation management became an obvious issue as the research progressed, hence the variations). The context was initially focussed on main roads, public works and John Holland group organisations but it became clear very quickly that this was in fact an industry-wide issue and not an issue specific solely to the project participants. Hence, the context within which this research took place can be described as below: The deliverables from the project are a toolkit for determining RM needs in an organisation, a monograph describing the practical implementation of RM and the outline for a RM CPD and Masters course

Impeding good governance implementation in Indonesian regional government : the effect of a bureaucratic generation gap

The implementation of ‘good governance’ in Indonesia’s regional government sector became a central tenet in governance research following the introduction of the national code for governance in 2006. The code was originally drafted in 1999 as a response to the Asian financial crises and many cases of unearthed corruption, collusion, and nepotism. It was reviewed in 2001 and again in 2006 to incorporate relevant political, economical, and social developments. Even though the national code exists along with many regional government decrees on good governance, the extent of implementation of the tenets of good governance in Indonesia’s regional government is still questioned. Previous research on good governance implementation in Indonesian regional government (Mardiasmo, Barnes and Sakurai, 2008) identified differences in the nature and depth of implementation between various Indonesian regional governments. This paper analyses and extends this recent work and explores key factors that may impede the implementation and sustained application of governance practices across regional settings. The bureaucratic culture of Indonesian regional government is one that has been shaped for over approximately 30 years, in particular during that of the Soeharto regime. Previous research on this regime suggests a bureaucratic culture with a mix of positive and negative aspects. On one hand Soeharto’s regime resulted in strong development growth and strong economic fundamentals, resulting in Indonesia being recognised as one of the Asian economic tigers prior to the 1997 Asian financial crises. The financial crises however revealed a bureaucratic culture that was rife with corruption, collusion, and nepotism. Although subsequent Indonesian governments have been committed to eradicating entrenched practices it seems apparent that the culture is ingrained within the bureaucracy and eradication of it will take time. Informants from regional government agree with this observation, as they identify good governance as an innovative mechanism and to implement it will mean a deviation from the “old ways.” Thus there is a need for a “changed” mind set in order to implement sustained governance practices. Such an exercise has proven to be challenging so far, as there is “hidden” resistance from within the bureaucracy to change its ways. The inertia of such bureaucratic cultures forms a tension against the opportunity for the implementation of good governance. From this context an emergent finding is the existence of a ‘bureaucratic generation gap’ as an impeding variable to enhanced and more efficient implementation of governance systems. It was found that after the Asian financial crises the Indonesian government (both at national and regional level) drew upon a wider human resources pool to fill government positions – including entrants from academia, the private sector, international institutions, foreign nationals and new graduates. It suggested that this change in human capital within government is at the core of this ‘inter-generational divide.’ This divergence is exemplified, at one extreme, by [older] bureaucrats who have been in-position for long periods of time serving during the extended Soeharto regime. The “new” bureaucrats have only sat in their positions since the end of Asian financial crisis and did not serve during Soeharto’s regime. It is argued that the existence of this generation gap and associated aspects of organisational culture have significantly impeded modernising governance practices across regional Indonesia. This paper examines the experiences of government employees in five Indonesian regions: Solok, Padang, Gorontalo, Bali, and Jakarta. Each regional government is examined using a mixed methodology comprising of on-site observation, document analysis, and iterative semi-structured interviewing. Drawing from the experiences of five regional governments in implementing good governance this paper seeks to better understand the causal contexts of variable implementation governance practices and to suggest enhancements to the development of policies for sustainable inter-generational change in governance practice across regional government settings.

Construction supply chain economic policy implementation for sectoral change : moving beyond the rhetoric

Construction sector policy makers have the opportunity to create improvements and develop economic, social and environmental sustainability through supply chain economics. The idea of the supply chain concept to improve firm behaviour and industry performance is not new. However there has been limited application and little or no measurement to monitor successful implementation. Often purchasing policies have been developed with sound strategic procurement principles but even these have had limited penetration in to the processes and practices of infrastructure agencies. The research reported in this paper documents an action research study currently being undertaken in the Australian construction sector which aims to explore supply chain economic policy implementation for sectoral change by two government agencies. The theory which informs this study is the emerging area of construction supply chain economics. There are five stages to the project including; demand analysis, chain analysis, government agency organizational audit, supplier strategy and strategic alignment. The overall objective is towards the development of a Supplier Group Strategy Map for two public sector agencies. Two construction subsectors are examined in detail; construction and demolition waste and precast concrete. Both of these subsectors are critical to the economic and environmental sustainability performance of the construction sector and the community as a whole in the particular jurisdictions. The local and state government agencies who are at the core of the case studies rely individually on the performance of these sectors. The study is set within the context of a sound state purchasing policy that has however, had limited application by the two agencies. Partial results of the study are presented and early findings indicate that the standard risk versus expenditure procurement model does not capture the complexities of project, owner and government risk considerations. A new model is proposed in this paper, which incorporates the added dimension of time. The research results have numerous stakeholders; they will hold particular value for those interested in regional construction sector economics, government agencies who develop and implement policy and who have a large construction purchasing imprint and the players involved in the two subsectors. Even though this is a study in Australia it has widespread applicability as previous research indicates that procurement reform is of international significance and policy implementation is problematic.

Electronic Tendering : Guidelines and Recommendations for Successful Implementation and Uptake

This publication, summarising outcomes of an investigation into eTendering as a part of a CRC Construction Innovation research project, presents guidelines and recommendations to be considered when implementing eTendering systems, procedures and policies.

Implementation of an integrated, technology-based, discovery mode assessment item involving an incubation period to enhance learning outcomes for engineering maths students

In this paper we discuss our current efforts to develop and implement an exploratory, discovery mode assessment item into the total learning and assessment profile for a target group of about 100 second level engineering mathematics students. The assessment item under development is composed of 2 parts, namely, a set of "pre-lab" homework problems (which focus on relevant prior mathematical knowledge, concepts and skills), and complementary computing laboratory exercises which are undertaken within a fixed (1 hour) time frame. In particular, the computing exercises exploit the algebraic manipulation and visualisation capabilities of the symbolic algebra package MAPLE, with the aim of promoting understanding of certain mathematical concepts and skills via visual and intuitive reasoning, rather than a formal or rigorous approach. The assessment task we are developing is aimed at providing students with a significant learning experience, in addition to providing feedback on their individual knowledge and skills. To this end, a noteworthy feature of the scheme is that marks awarded for the laboratory work are primarily based on the extent to which reflective, critical thinking is demonstrated, rather than the amount of CBE-style tasks completed by the student within the allowed time. With regard to student learning outcomes, a novel and potentially critical feature of our scheme is that the assessment task is designed to be intimately linked to the overall course content, in that it aims to introduce important concepts and skills (via individual student exploration) which will be revisited somewhat later in the pedagogically more restrictive formal lecture component of the course (typically a large group plenary format). Furthermore, the time delay involved, or "incubation period", is also a deliberate design feature: it is intended to allow students the opportunity to undergo potentially important internal re-adjustments in their understanding, before being exposed to lectures on related course content which are invariably delivered in a more condensed, formal and mathematically rigorous manner. In our presentation, we will discuss in more detail our motivation and rationale for trailing such a scheme for the targeted student group. Some of the advantages and disadvantages of our approach (as we perceived them at the initial stages) will also be enumerated. In a companion paper, the theoretical framework for our approach will be more fully elaborated, and measures of student learning outcomes (as obtained from eg. student provided feedback) will be discussed.