The cost effective management of Central Line-Associated Bloodstream Infections (CLABSIs) comparing the central line bundle to antimicrobialcoated central venous catheters: A systematic review

Central Line-Associated Bloodstream Infections (CLABSIs) are one of the most costly and preventable cases of morbidity and mortality among intensive care units (ICUs) in health care today. In 2008, the Centers for Medicare and Medicaid Services Medicare Program, under the Deficit Reduction Act, announced it will no longer reimburse hospitals for such adverse events among those related to CLABSIs. This reveals the financial burden shift onto the hospital rather than the health care payer who can now withhold reimbursements. With this weighing more heavily on hospital management, decision makers will need to find a way to completely prevent cases of CLABSI or simply pay for the financial consequences. ^ To reduce the risk of CLABSIs, several clinical, preventive interventions have been studied and even instituted including the Central Line (CL) Bundle and Antimicrobial Coated Central Venous Catheters (AM-CVCs). I carried out a formal systematic review on the topic to compare the cost-effectiveness of the Central Line (CL) Bundle to the commercially available antimicrobial coated central venous catheters (AM-CVCs) in preventing CLABSIs among critically and chronically ill patients in the U.S. Evidence was assessed for inclusion against predefined criteria. I, myself, conducted the data extraction. Ten studies were included in the review. Efficacy in reducing the mean incidence rate of CLABSI by the CL Bundle and AM-CVC interventions were compared with one another including costs. ^ The AM-CVC impregnated with antibiotics, rifampin-minocycline (AI-RM) is more clinically effective than the CL Bundle in reducing the mean rate of CLABSI per 1,000 catheter days. The lowest mean incidence rate of CLABSI per 1,000 catheter days among the AM-CVC studies was as low as zero in favor of the AI-RM. Moreover, the review revealed that the AI-RM appears to be more cost-effective than the CL Bundle. Results showed the adjusted incremental cost of the CL Bundle per ICU patient requiring a CVC to be approximately $196 while the AI-RM at only an additional cost of $48 per ICU patient requiring a CVC. ^ Limited data regarding the cost of the CL Bundle made it difficult to make a true comparison to the direct cost of the AM-CVCs. However, using the result I did have from this review, I concluded that the AM-CVCs do appear to be more cost-effective in decreasing the mean rate of CLABSI while also minimizing incremental costs per CVC than the CL Bundle. This review calls for further research addressing the cost of the CL Bundle and compliance and more effective study designs such as randomized control trials comparing the efficacy and cost of the CL Bundle to the AM-CVCs. Barriers that may face health care managers when implementing the CL Bundle or AM-CVCs include additional costs associated with the intervention, educational training and ongoing reinforcement as well as creating a new culture of understanding.^

Do Australian public sector employees have the type of culture they want in the era of new public management?

New public management theory proposes that public sector organisations should be managed more like private sector organisations. It is therefore expected that public sector managers will have preferences for an organisational culture that will reflect the culture of private sector organisations, with an external rather than internal orientation. The current research investigated the idea that managers' perceptions of ideal organisational culture would be different to the bureaucratic model of culture (internally oriented), which has traditionally been associated with public sector organisations. Responses to a competing values culture inventory were received from 925 public sector employees. Results indicated that the bureaucratic model is still pervasive; however, managers prefer a culture that is more external, and less control focussed, as expected. Lower level employees expressed a desire for a culture that emphasised human relations values.

Optimum inclusion of field peas, faba beans, chick peas and sweet lupins in poultry diets. II. Broiler experiments

1. Three experiments were undertaken to determine the optimum inclusion rates of held peas, faba beans, chick peas and sweet lupins in broiler starter and finisher diets in amounts up to 360 g/kg. 2. In experiment A chickens in cages grown to 21 d on diets with field peas and faba beans gave better growth rate and feed efficiency than those with sweet lupins and chick peas. Growth rate and Food conversion ratio (FCR) improved with increasing amounts of faba beans in the diet while for chick peas growth rate and FCR declined. Digesta viscosity and excreta stickiness scores were much higher on diets with sweet lupins. Steam pelleting improved growth rate and FCR on all diets. 3. In experiment B birds were in cages and grown from 21 to 42 d. There were no differences between grain legumes (when combined for all inclusions) for growth rate, food intake or FCR. Viscosity was again much higher on the sweet lupin-based diets while the pancreas was significantly enlarged on the diets with chick peas, as observed previously in chickens grown to 21 d. Steam pelleting of diets gave a consistent and positive response for weight gain and FCR. 4. Experiment C was carried out in pens each holding 60 birds under semi-commercial conditions and grown to 4 2 d on starter and finisher diets with the same grain legumes as used previously but each at 2 rates of inclusion similar to those in commercial practice. Field peas at 200 to 300 g/kg and chick peas at 150 to 220 g/kg gave inferior growth to faba beans (150 to 180 g/kg) and sweet lupins (120 g/kg). 5. The results of these experiments allowed tentative recommendations to be made to industry for inclusion rates of these cultivars of the 4 grain legumes. These were: field peas 300 g/kg; faba beans 200 g/kg, chick peas 100 g/kg and sweet lupins

Nonmetallic inclusion modification and its effect on the final properties of a linepipe steel

Five linepipe type steels were produced in order to study the effect of calcium and magnesium injection on their final properties. Two of these steels were at the extremes of the sulphide range i.e. 0.003 and 0.017% sulphur with no injection attempted; thereby, providing standards to compare with the injected steels. The oxygen level varied from 21 to 63 p.p.m. The cast ingots were controlled-rolled and isothermally rolled in order to study the deformation characteristics of the residual non-metallic inclusions. The structure and cleanliness of these steels was evaluated metallographically using the light microscope, SEM, and image analysis and the results related to their Charpy toughness and HIC resistance. Increasing sulphur levels decreased final properties of the steel. In the untreated state, with as little as 0.003% sulphur, test orientation was highly influential. Modification of sulphur bearing steels was achieved with low modifying element to sulphur ratios provided that the oxygen content was very low. Injection of calcium into steel caused interaction with oxide and sulphide inclusions which was biased toward oxide reduction relative to sulphur removal. Magnesium again reduced oxides and appeared to be linked with aluminia containing inclusions in the final product. It produced improved toughness values relative to a similar sulphur containing calcium treated steel. The results of this work could be extended to establish the mechanism of inclusion modification with magnesium additions to sulphur bearing steels.

Development of a neurotoxicity test-system, using human post-mitotic, astrocytic and neuronal cell lines in co-culture

Astrocytes are essential for neuronal function and survival, so both cell types were included in a human neurotoxicity test-system to assess the protective effects of astrocytes on neurons, compared with a culture of neurons alone. The human NT2.D1 cell line was differentiated to form either a co-culture of post-mitotic NT2.N neuronal (TUJ1, NF68 and NSE positive) and NT2.A astrocytic (GFAP positive) cells (∼2:1 NT2.A:NT2.N), or an NT2.N mono-culture. Cultures were exposed to human toxins, for 4 h at sub-cytotoxic concentrations, in order to compare levels of compromised cell function and thus evidence of an astrocytic protective effect. Functional endpoints examined included assays for cellular energy (ATP) and glutathione (GSH) levels, generation of hydrogen peroxide (H2O2) and caspase-3 activation. Generally, the NT2.N/A co-culture was more resistant to toxicity, maintaining superior ATP and GSH levels and sustaining smaller significant increases in H2O2 levels compared with neurons alone. However, the pure neuronal culture showed a significantly lower level of caspase activation. These data suggest that besides their support for neurons through maintenance of ATP and GSH and control of H2O2 levels, following exposure to some substances, astrocytes may promote an apoptotic mode of cell death. Thus, it appears the use of astrocytes in an in vitro predictive neurotoxicity test-system may be more relevant to human CNS structure and function than neuronal cells alone. © 2007 Elsevier Ltd. All rights reserved.

The sound of silence. Lesbian, gay, bisexual and transgender discrimination in 'inclusive organizations'

Most studies on diversity and discrimination in the workplace have focused on 'visible' minorities such as gender or race, often neglecting the experiences of invisible minorities such as lesbian, gay, bisexual and transgender (LGBT) workers. In this paper we explore the practices of inclusion/exclusion of LGBTs in the workplace in Italian social cooperatives, which are specifically founded to create employment for people who are disadvantaged in the labour market. The study examines how organizations, which have an ethos focused on inclusion and mainly employ workers from specific social minority groups, manage the inclusion of LGBT workers. We also explore the experience of LGBT workers within these organizations. The paper reports that the culture of silence existing in the five organizations studied prevents LGBT employees from constructing a work identity which encompasses their sexual identity and prevents the organizations from achieving their aim of being fully inclusive workplaces. © 2013 British Academy of Management.

Brain-derived neurotrophic factor as an indicator of chemical neurotoxicity:an animal-free CNS cell culture model

Recent changes to the legislation on chemicals and cosmetics testing call for a change in the paradigm regarding the current 'whole animal' approach for identifying chemical hazards, including the assessment of potential neurotoxins. Accordingly, since 2004, we have worked on the development of the integrated co-culture of post-mitotic, human-derived neurons and astrocytes (NT2.N/A), for use as an in vitro functional central nervous system (CNS) model. We have used it successfully to investigate indicators of neurotoxicity. For this purpose, we used NT2.N/A cells to examine the effects of acute exposure to a range of test chemicals on the cellular release of brain-derived neurotrophic factor (BDNF). It was demonstrated that the release of this protective neurotrophin into the culture medium (above that of control levels) occurred consistently in response to sub-cytotoxic levels of known neurotoxic, but not non-neurotoxic, chemicals. These increases in BDNF release were quantifiable, statistically significant, and occurred at concentrations below those at which cell death was measureable, which potentially indicates specific neurotoxicity, as opposed to general cytotoxicity. The fact that the BDNF immunoassay is non-invasive, and that NT2.N/A cells retain their functionality for a period of months, may make this system useful for repeated-dose toxicity testing, which is of particular relevance to cosmetics testing without the use of laboratory animals. In addition, the production of NT2.N/A cells without the use of animal products, such as fetal bovine serum, is being explored, to produce a fully-humanised cellular model.

modern foreign languages classroom:is inclusion of all exclusion in disguise?

The past decade has seen a drive to give all pupils the opportunity to study a Modern Foreign Language (MFL) in schools in England, making the teaching and learning of foreign languages part of the primary school curriculum. The Languages for All: Languages for Life (DfES, 2002) policy was introduced through the National Languages Strategy with an objective to increase the nation’s language capability. Raising the educational standard for all pupils is another government initiative with a strong emphasis on inclusion. As the Languages for All policy stresses the importance and benefits of language learning, and inclusion suggests equality and provision for all, this study examines the inclusion of all key stage 2 pupils in foreign language learning and describes perceptions and experiences of pupils, particularly those identified as having special educational needs (SEN) in their performances and negotiations in learning French. As a small scale, qualitative and ethnographically informed, this research is based on participant observation and semi-structured interviews with pupils, teachers of French, teaching assistants and parents. This study draws upon Nussbaum’s capabilities approach and Bourdieu’s concepts as theoretical foundations to analyse the ‘inclusive’ French classroom. As the capabilities approach takes people as ends not means, and goes beyond a focus on resources, it lends itself to critical thinking on issues around inclusion in education. In this context, this researcher investigates the experiences of pupils who struggle with foreign language learning because of their abilities or disabilities, and frames the discussion around the capabilities approach. The study also focuses on motivation and identity in foreign language learning, and draws upon Bourdieu’s concepts of capital, habitus and field to analyse how the participants make sense of and respond to their own circumstances in relation to their performances in the language learning process. This research thus considers Bourdieu’s concepts for a deeper understanding of issues of inequality in learning French and takes up Nussbaum’s insight that pupils may differ in what learning French means to them, and it is not how they differ, but the difference between their capability to choose and achieve what they value that should matter. The findings indicate that although, initially, the French classroom appears ‘inclusive’ due to the provision and practices of inclusion, a closer look shows it to be exclusionary. In addition, responses from the participants on the usefulness and benefits of foreign language learning are contradictory to the objectives of the Languages for All policy, illustrating the complexity of the ‘inclusive’ MFL classroom. This research concludes that structural and interpersonal practices of inclusion contribute to the disguising of exclusion in a classroom deemed ‘inclusive’. Implications are that an understanding and consideration of other aspect of life such as well-being, interests, needs and values should form a necessary part of the language policy.

The influence of culture and market orientation on services brands:insights from Irish banking and retail firms

Purpose: This paper aims to examine the influence of the culture of the service firm on its interpretation of the role of the brand and on the development and implementation of its brand values. Design/methodology/approach: A grounded theory approach was used. Interviews were conducted with 20 managers within two leading banking firms in Ireland and two leading grocery retailers in Ireland. Findings: The development of the brand, and its role within the firm, is closely related to the firm's culture. The research shows obstacles and opportunities created by the cultural context of firms wishing to disseminate and embed a set of brand values. The paper presents an "involvement model" of brand values implementation and outlines changes required to implement brand values. Research limitations/implications: The study was bound by access to firms, and managers' availability. The authors sought an insight into the relationship between each firm's culture and its brands. They advocate quantitative research to further investigate the findings within these service sectors and to test proposed antecedents (transformational leadership, employee involvement) and outcomes (employee-based brand equity and consumer-based brand equity) of values adoption. Practical implications: The paper identifies aspects of retail and banking cultures which support or detract from brand development. In particular, it presents the learnings from successful brand values implementation in a clan culture, aspects of which are applicable across other cultures. Originality/value: The paper provides valuable insights into the role of the brand within the service firm and the positive and negative influence of context on brand values and their development and implementation. © Emerald Group Publishing Limited.

An examination of parental opinions regarding the inclusion of disabled students in regular education classes

This study investigated the opinions regarding inclusion of parents of both disabled and nondisabled elementary children from a large suburban county. An opinion survey combining Wilczenski's Attitudes Toward Inclusive Education Scale with additional questions was distributed to 1170 children from 24 schools. Three research questions focused on differences between mean parental responses as they related to the inclusion and disability status of the parent's child. Results from the 270 respondents indicated that parents with disabled children had more favorable opinions about inclusion than did those with nondisabled children. Parents with included children were more favorable toward inclusion than were parents whose children were not included. Parents with included disabled children were more accepting of inclusion than were those with nondisabled children in inclusive settings. Parents' answers differed depending on the type of disability being included. Regardless of their child's disability or inclusion status, the ranking for disability types from most acceptable for inclusion to least acceptable were: social, sensory, motor, academic and behavioral. Results across types of questions, including questions relating to acceptance and general inclusion issues, indicated consistently more favorable opinions of parents with disabled children, included children and disabled children in inclusive classes. Two additional research questions examined parental responses as they related to demographic characteristics of the parents and of the schools their children attended. Analysis of Variance found only one significant main effect for any parental demographic variable. This difference was for the number of parents' elementary children when comparing parents with and without disabled children. The only significant main effects of demographics of schools the parents' children attended were for the area of the county and for schools with differing percentages of severely disabled students when comparing responses of parents with disabled and nondisabled children. For all research questions, tests indicated low effect sizes and moderate to high power levels. These results, and the fact that means for all groups were in the middle range of response choices, indicate that there may be little practical significance to the overall results. Further studies should investigate the trends found in this study. ^

Middle school teachers perspectives on inclusion: A qualitative study

Historically, research has placed considerable emphasis on developing a systematic body of knowledge about education in which little voice has been given to teachers themselves. The critical role that teachers play in this generative process such as reflecting, acting and theorizing upon practices that shape life in the classroom has largely been ignored in favor of technical innovation and organizational procedure. As schools struggle to reform and restructure, an understanding of how teachers interpret their practices in context and how the culture of schools influence, constrain, or encourage these practices become critical aspects of school success or failure. ^ This study examined the perspectives on inclusion of seven middle school teachers as they attempted to include exceptional students in regular classes. The study utilized three forms of data collection: observations were made of participant interactions as they led their everyday school lives; document analysis was used as a means to gain an understanding of programs affecting exceptional students, and interviews were used to give voice to teacher's perceptions regarding inclusion, allowing description in their own words rather than those imposed by an outside inquirer. Data collection and analysis sought to identify emerging themes, categories and patterns, allowing for the creation of substantive theory grounded in empirical data. ^ The key issues that emerged in the study were considered in terms of three general categories. The first, teaching and learning, revealed stark contrasts in opinions regarding the type of human support thought necessary for successful inclusion. Regular educators clung to the traditional notion of solitary teachers directing all class activity, while exceptional educators preferred a more team-oriented approach. The second, school structure, revealed that highly collaborative structures were only partially successful in creating additional conversation between regular and exceptional educators. Collegiality was affected by lack of staff experience with the process as well as its implementation in a top-down fashion. The third, school culture and climate, revealed that regular educators believed the school was prepared for a limited amount of inclusion. Although exceptional educators acknowledged school readiness, they did not believe that inclusion was an important item on the school's reform agenda. ^

The maintenance of tracking: The role of organizational culture

Modern comprehensive high schools do not formally track students into different programs, but schools offer different curricular sequences with important and stratified consequences for students' post-secondary education. This study used qualitative methodology to examine how schools' organizational cultures influence the maintenance of tracking practices in four comprehensive high schools in Miami. The methodology included long-term participant observation in each of the four schools, unstructured and semi-structured interviews and the collection of written documents produced by the district. A framework based on the concepts of environment, mission, information, strategy, and leadership was used to analyze the data. ^ It was found that school cultures shared deeply held beliefs that regard ability as a fixed trait. This prevented schools from providing access to information about the consequences of course selection to the majority of the student body, with the exception of those students defined as “college bound.” State and County level policies that reward achievement in standardized tests combined with school overcrowding, resulted in organizational cultures that favored the adoption of strategies stressing efficiency, as opposed to a challenging education for all students. Only one of the four schools in the study had a policy requiring students to attempt courses that were more challenging. The practice was resented by both teachers and counselors, since it was perceived as interfering with other goals of the institution, i.e.: graduating students in four years. ^ The culture of the schools stressed college as the only legitimate post-secondary option; consequently, the majority of counselors did not encourage students—even those already defined as “not college material”—to consider other alternatives, such as vocational education. The elimination of formal tracks in these comprehensive high schools resulted in the school culture lacking a clear mission in regards to non-college bound students. Findings are discussed in relation to current theoretical explanations for educational policy and equality of opportunity. ^

The impact of the Miami Cuban exile's political culture on the 1996 fiscal crisis of the city of Miami

The purpose of this study was to determine if the political culture of the Miami Cuban exile community was a significant factor in creating the environment that led to the 1996 fiscal crisis of the City of Miami. The study performed an ethnographic case study that utilized a triangulation strategy which included both qualitative and quantitative methods. Focus groups were conducted to ascertain qualitative and quantitative data as to differences among ethnic and generational groups regarding notions of governance, public administration practices, and overall political values and core beliefs. Quantitative data was obtained through a five year and seven month review of newspaper articles from two periodicals based in Miami-Dade County. A review was also conducted of secondary data in audit and management reports, blue ribbon commission studies, Certified Public Manager (CPM) enrollment, and legal case decisions to examine the administrative practices of the City of Miami leading up to and subsequent to its fiscal crisis. The study found that a political subculture of caudillismo was present in Cuban exile core areas of Miami that appears to have had an influence on the administrative practices and notions of governance that led to the fiscal crisis. The author concludes that an imported foreign political culture has imposed itself as a subculture in core areas of the exile community and that the operationalization of this subculture has manifested itself in non-mainstream notions of governance and public administration practices. ^