Stress on the ward: evidence of safety tipping points in hospitals

Do hospitals experience safety tipping points as utilization increases, and if so, what are the implications for hospital operations management? We argue that safety tipping points occur when managerial escalation policies are exhausted and workload variability buffers are depleted. Front-line clinical staff is forced to ration resources and, at the same time, becomes more error prone as a result of elevated stress hormone levels. We confirm the existence of safety tipping points for in-hospital mortality using the discharge records of 82,280 patients across six high-mortality-risk conditions from 256 clinical departments of 83 German hospitals. Focusing on survival during the first seven days following admission, we estimate a mortality tipping point at an occupancy level of 92.5%. Among the 17% of patients in our sample who experienced occupancy above the tipping point during the first seven days of their hospital stay, high occupancy accounted for one in seven deaths. The existence of a safety tipping point has important implications for hospital management. First, flexible capacity expansion is more cost-effective for safety improvement than rigid capacity, because it will only be used when occupancy reaches the tipping point. In the context of our sample, flexible staffing saves more than 40% of the cost of a fully staffed capacity expansion, while achieving the same reduction in mortality. Second, reducing the variability of demand by pooling capacity in hospital clusters can greatly increase safety in a hospital system, because it reduces the likelihood that a patient will experience occupancy levels beyond the tipping point. Pooling the capacity of nearby hospitals in our sample reduces the number of deaths due to high occupancy by 34%.

超对称电磁相互作用系统的BRST量子化及其正则Ward恒等式

运用Becchi-Rouet-Stora-Tyutin路径积分量子化方法对超对称电磁相互作用系统进行了量子化.在相空间中化简了超对称电磁相互作用系统Hamiltonian量,进而使该系统的量子化被化简.构造体系的BRST生成元,得到了系统的BRST变换;给出了有效作用量,得到了Green函数生成泛函;构造了体系的规范生产元,并得到了系统的规范对称变换.最后,基于正则系统的Noether定理,给出了规范变换的Ward-Takahashi恒等式,进而讨论了正规顶角和传播子的关系,给出了正规顶角和传播子的两个关系式.

BRST quantization and canonical Ward identity of the supersymmetric electromagnetic interaction system

According to the method of path integral quantization for the canonical constrained system in Becchi-Rouet-Stora-Tyutin scheme, the supersymmetric electromagnetic interaction system was quantized. Both the Hamiltonian of the supersymmetric electromagnetic interaction system in phase space and the quantization procedure were simplified. The BRST generator was constructed, and the BRST transformations of supersymmetric fields were gotten; the effective action was calculated, and the generating functional for the Green function was achieved; also, the gauge generator was constructed, and the gauge transformation of the system was obtained. Finally, the Ward-Takahashi identities based on the canonical Noether theorem were calculated, and two relations between proper vertices and propagators were obtained.

A view of the history, literature, and religion of the Hindoos : including a minute description of their manners and customs, and translations from their principal works / by Rev. W. Ward.

http://www.archive.org/details/wardshidoos00sethuoft

Distance between home and work: A multilevel analysis of individual workers, neighbourhoods, and employment sites in Northern Ireland

Abstract. We explore the distances between home and work for employees at twenty-eight different employment sites across Northern Ireland. Substantively, this is important for better understanding the geography of labour catchments. Methodologically, with data on the distances between place of residence (566 wards) and place of work for some 15 000 workers, and the use of multilevel modelling (MLM), the analysis adds to the evidence derived from other census-based and survey-based studies. Descriptive analysis is supplemented with MLM that simultaneously explores individual, neighbourhood, and site variations in travel-to-work patterns using hierarchical and cross-classified model specifications, including individual and ecological predictor variables (and their cross-level interactions). In doing so we apportion variability to different levels and spatial contexts, and also outline the factors that shape spatial mobility. We find, as expected, that factors such as gender and occupation influence the distance between home and work, and also confirm the importance of neighbourhood characteristics (such as population density observed in ecological analyses at ward level) in shaping individual outcomes, with major differences found between urban and rural locations. Beyond this, the analysis of variability also points to the relative significance of residential location, with less individual variability in travel-to-work distance between workers within wards than within employment sites. We conclude by suggesting that, whilst some general ‘rules’ about the factors that shape labour catchments are possible (eg workers in rural areas and in higher occupations travel further than others), the complex variability between places highlighted by the MLM analysis illustrates the salience of place-specific uniqueness.