The development of an online neonatal intensive care unit family education

Background: British Columbia’s Fraser Health Authority (FHA) neonatal intensive care units (NICUs) value family centered care (FCC). Nevertheless, there is limited evidence that FCC is actually incorporated into practice, as well as some concern that FHA NICU education is inaccessible, inconsistent, or disorganized. Purpose: The mission of this project is to support the principles of FCC throughout the development of an FHA online NICU family education guide by reflecting upon the needs of families throughout their NICU journey. Methods: A needs assessment was initially completed and included literature reviews, consultations, and an environmental scan. This data informed development of an online NICU family education guide which plots current education materials along key stages of the NICU journey: prenatal, admission, early days, growing and developing, discharge and at home. For the purposes of this practicum, only the prenatal stage was fully developed and will serve as a template for other stages following a formative evaluation. A pamphlet and revised FHA Neonatal Checkpoint will also be developed to augment teaching by health care professionals. Implementation and evaluation plans were adapted from the Center for Disease Control Framework for Program Evaluation in Public Health. Results: The needs assessment validates and directs the development, implementation, and evaluation of the online guide illustrating an FCC approach. The online guide centralizes and organizes education by selecting education topics that relate to each stage of the NICU journey. This family-directed design enables families’ access to consistent and reliable information and offers them an opportunity to learn at their own pace. Conclusion: The process of creating, implementing, and evaluating an online family education program for FHA NICUs elucidates the intricacies and the advantages of integrating FCC into NICU practice.

Windscapes shape seabird instantaneous energy costs but adult behavior buffers impact on offspring

Acknowledgements K. Ashbrook, M. Barrueto, K. Elner, A. Hargreaves, S. Jacobs, G. Lancton, M. LeVaillant, E. Grosbellet, A. Moody, A. Ronston, J. Provencher, P. Smith, K. Woo and P. Woodward helped in the field. J. Nakoolak kept us safe from bears. N. Sapir and two anonymous reviewers provided very useful comments on an earlier version of our manuscript. R. Armstrong at the Nunavut Research Institute, M. Mallory at the Canadian Wildlife Service Northern Research Division and C. Eberl at National Wildlife Research Centre in Ottawa provided logistical support. F. Crenner, N. Chatelain and M. Brucker customized the GPS at the IPHC-CNRS. KHE received financial support through a NSERC Vanier Canada Graduate Scholarship, ACUNS Garfield Weston Northern Studies scholarship and AINA Jennifer Robinson Scholarship and JFH received NSERC Discovery Grant funding. J. Welcker generously loaned some accelerometers. All procedures were approved under the guidelines of the Canadian Council for Animal Care.

Operational expenditure costs for wave energy projects and impacts on financial returns

This paper examines 'availability' and the input metrics of operational expenditure (OPEX) for wave energy projects and reports on a case study which assesses the impact of these inputs on project profit returns. Case study simulations modelled a 75 MW wave energy project at two locations; the west coast of Ireland and the north coast of Portugal. Access and availability with respect to weather windows at both locations are discussed and their impact on energy output and wave farm operations is quantified. The input metrics used to calculate OPEX of wave energy projects are defined as well as the impact of OPEX on project net present value (NPV) and internal rate of return (IRR). Results indicate that access and resultant availability factors have a significant impact on case study results by reducing energy output and correspondingly financial returns. Furthermore, the technology maturity level designated for a project also impacts on availability factors and consequently energy output and NPV. Case study profits proved to be very sensitive to annual OPEX, especially if overhaul and replacement costs were accounted for. As a result of the impact of 'availability' on project profit returns. Feed-in tariffs will need to be tailored to the location in question as well as the device technology maturity level, with case study simulations indicating that high FIT will be required to support early stage WEC projects. (C) 2012 Elsevier Ltd. All rights reserved.

System operational costs reduction with non-conventional reactive power sources

Wind energy installations are increasing in power systems worldwide and wind generation capacity tends to be located some distance from load centers. A conflict may arise at times of high wind generation when it becomes necessary to curtail wind energy in order to maintain conventional generators on-line for the provision of voltage control support at load centers. Using the island of Ireland as a case study and presenting commercially available reactive power support devices as possible solutions to the voltage control problems in urban areas, this paper explores the reduction in total generation costs resulting from the relaxation of the operational constraints requiring conventional generators to be kept on-line near load centers for reactive power support. The paper shows that by 2020 there will be possible savings of 87€m per annum and a reduction in wind curtailment of more than a percentage point if measures are taken to relax these constraints.

Investigation of factors driving the costs of operating the 2020 Irish power system with large-scale wind generation

The main goal of this work is to determine the true cost incurred by the Republic of Ireland and Northern Ireland in order to meet their EU renewable electricity targets. The primary all-island of Ireland policy goal is that 40% of electricity will come from renewable sources in 2020. From this it is expected that wind generation on the Irish electricity system will be in the region of 32-37% of total generation. This leads to issues resulting from wind energy being a non-synchronous, unpredictable and variable source of energy use on a scale never seen before for a single synchronous system. If changes are not made to traditional operational practices, the efficient running of the electricity system will be directly affected by these issues in the coming years. Using models of the electricity system for the all-island grid of Ireland, the effects of high wind energy penetration expected to be present in 2020 are examined. These models were developed using a unit commitment, economic dispatch tool called PLEXOS which allows for a detailed representation of the electricity system to be achieved down to individual generator level. These models replicate the true running of the electricity system through use of day-ahead scheduling and semi-relaxed use of these schedules that reflects the Transmission System Operator's of real time decision making on dispatch. In addition, it carefully considers other non-wind priority dispatch generation technologies that have an effect on the overall system. In the models developed, three main issues associated with wind energy integration were selected to be examined in detail to determine the sensitivity of assumptions presented in other studies. These three issues include wind energy's non-synchronous nature, its variability and spatial correlation, and its unpredictability. This leads to an examination of the effects in three areas: the need for system operation constraints required for system security; different onshore to offshore ratios of installed wind energy; and the degrees of accuracy in wind energy forecasting. Each of these areas directly impact the way in which the electricity system is run as they address each of the three issues associated with wind energy stated above, respectively. It is shown that assumptions in these three areas have a large effect on the results in terms of total generation costs, wind curtailment and generator technology type dispatch. In particular accounting for these issues has resulted in wind curtailment being predicted in much larger quantities than had been previously reported. This would have a large effect on wind energy companies because it is already a very low profit margin industry. Results from this work have shown that the relaxation of system operation constraints is crucial to the economic running of the electricity system with large improvements shown in the reduction of wind curtailment and system generation costs. There are clear benefits in having a proportion of the wind installed offshore in Ireland which would help to reduce variability of wind energy generation on the system and therefore reduce wind curtailment. With envisaged future improvements in day-ahead wind forecasting from 8% to 4% mean absolute error, there are potential reductions in wind curtailment system costs and open cycle gas turbine usage. This work illustrates the consequences of assumptions in the areas of system operation constraints, onshore/offshore installed wind capacities and accuracy in wind forecasting to better inform the true costs associated with running Ireland's changing electricity system as it continues to decarbonise into the near future. This work also proposes to illustrate, through the use of Ireland as a case study, the effects that will become ever more prevalent in other synchronous systems as they pursue a path of increasing renewable energy generation.

Assessing Surveillance Elements of the Zanzibar Malaria Elimination Program to Support Malaria Elimination in Zanzibar

Though significant progress has been made through control efforts in recent years, malaria remains a leading cause of morbidity and mortality throughout the world, with 3.2 billion people at risk of developing the disease. Zanzibar is currently pursuing malaria elimination through the Zanzibar Malaria Elimination Program (ZAMEP), and is working toward a goal of no locally acquired malaria cases by 2018. A comprehensive and well functioning malaria surveillance program is central to achieving this goal. Under ZAMEP’s current surveillance strategy, District Malaria Surveillance Officers (DMSOs) respond to malaria case notifications through the reactive case detection (RACD) system. Three malaria screening and treatment strategies are undertaken in response to this system, including household-level (HSaT), focal-level (FSaT), and mass-level (MSaT). Each strategy is triggered by a different case threshold and tests different-sized populations. The aims of this study were to (1) assess the cost effectiveness of three malaria screening and treatment strategies; (2) assess the timeliness and completeness of ZAMEP’s RACD system; (3) and qualitatively explore the roles of DMSOs.

Screening disposition and budget information for 2014 screening and treatment strategies was analyzed to determine prevalence rates in screened populations and the cost effectiveness of each strategy. Prevalence rates within the screened population varied by strategy: 6.1 percent in HSaT, 1.2 percent in FSaT, and 0.9 percent in MSaT. Of the various costing scenarios considering cost per person screened, MSaT was the most cost-effective, with costs ranging from $9.57 to $12.57 per person screened. Of the various costing scenarios considering cost per case detected, HSaT was the most cost-effective, at $385.51 per case detected.

Case data from 2013 through mid-2015 was used to assess the timeliness and completeness of the RACD system. The average number of RACD activities occurring within 48 hours of notification improved slightly between 2013 and the first half of 2015, from 90.7 percent to 93.1 percent. The average percentage of household members screened during RACD also increased over the same time period, from 84 percent in 2013 to 89.9 percent in the first half of 2015.

Interviews with twenty DMSOs were conducted to gain insights into the challenges to malaria elimination both from the health system and the community perspectives. Major themes discussed in the interviews include the need for additional training, inadequate information capture at health facility, resistance to household testing, transportation difficulties, inadequate personnel during the high transmission season, and community misinformation.

Zanzibar is now considered a low transmission setting, making elimination feasible, but also posing new challenges to achieving this goal. The findings of this study provide insight into how surveillance activities can be improved to support the goal of malaria elimination in Zanzibar. Key changes include reevaluating the use of MSaT activities, improving information capture at health facilities, hiring additional DMSOs during the high transmission season, and improving community communication.

Hearing the Child's Voice: Their Lived Experience in the Pediatric Intensive Care Unit

Background: More than 200,000 children are admitted annually to Pediatric Intensive Care Units (PICUs) in the US. Research has shown young children can provide insight into their hospitalization experiences; child reports rather than parental reports are critical to understanding the child’s experience. Information relating to children’s perceptions while still in the PICU is scarce. Aims: The purpose of this qualitative study was to investigate school age children’s and adolescents’ perceptions of PICU while in the PICU; changes in perceptions after transfer to the General Care Unit (GCU); differences in perceptions of school age children/adolescents and those with more invasive procedures. Methods: Interviews were conducted in PICU within 24-48 hours of admission and 24-48 hours after transfer to GCU. Data on demographics, clinical care and number/types of procedures were obtained. Results: Participants were 7 school age children, 13 adolescents; 10 Hispanic; 13 males. Five overarching themes: Coping Strategies, Environmental Factors, Stressors, Procedures/Medications, and Information. Children emphasized the importance of peer support and visitation; adolescents relied strongly on social media and texting. Parent visits sometimes were more stressful than peer visits. Video games, TV, visitors, and eating were diversional activities. In the PICU, they wanted windows to see outside and interesting things to see on the ceiling above them. Children expressed anticipatory fear of shots and procedures, frustration with lab work, and overwhelming PICU equipment. Number of child responses was higher in PICU (927) than GCU (593); the largest difference was in Environmental Factors. Variations between school age children and adolescents were primarily in Coping Strategies, especially in social support. Number of GCU procedures were the same (8 children) or greater (2 children) than PICU procedures. Discussion: Admission to PICU is a very stressful event. Perceptions from children while still in PICU found information not previously found in the literature. Longitudinal studies to identify children’s perceptions regarding PICU hospitalization and post-discharge outcomes are needed.

The Effects of Advanced Practice Nurses (APNs) as Intensivists in a Surgical Intensive Care Unit (SICU) on Patient Outcomes, Healthcare Charges, and APN Intensivist Services in the SICU

Intensive Care Units (ICUs) account for over 10 percent of all US hospital beds, have over 4.4 million patient admissions yearly, approximately 360,000 deaths, and account for close to 30% of acute care hospital costs. The need for critical care services has increased due to an aging population and medical advances that extend life. The result is efforts to improve patient outcomes, optimize financial performance, and implement models of ICU care that enhance quality of care and reduce health care costs. This retrospective chart review study examined the dose effect of APN Intensivists in a surgical intensive care unit (SICU) on differences in patient outcomes, healthcare charges, SICU length of stay, charges for APN intensivist services, and frequency of APNs special initiatives when the SICU was staffed by differing levels of APN Intensivist staffing over four time periods (T1-T4) between 2009 and 2011. The sample consisted of 816 randomly selected (204 per T1-T4) patient chart data. Study findings indicated reported ventilator associated pneumonia (VAP) rates, ventilator days, catheter days and catheter associated urinary tract infection (CAUTI) rates increased at T4 (when there was the lowest number of APN Intensivists), and there was increased pressure ulcer incidence in first two quarters of T4. There was no statistically significant difference in post-surgical glycemic control (M = 142.84, SD= 40.00), t (223) = 1.40, p = .17, and no statistically significant difference in the SICU length of stay among the time-periods (M= 3.27, SD = 3.32), t (202) = 1.02, p= .31. Charges for APN services increased over the 4 time periods from $11,268 at T1 to $51,727 at T4 when a system to capture APN billing was put into place. The number of new APN initiatives declined in T4 as the number of APN Intensivists declined. Study results suggest a dose effect of APN Intensivists on important patient health outcomes and on the number of APNs initiatives to prevent health complications in the SICU.

The epidemiology, healthcare and societal burden and costs of asthma in the UK and its member nations: analyses of standalone and linked national databases

Background: There are a lack of reliable data on the epidemiology and associated burden and costs of asthma. We sought to provide the first UK-wide estimates of the epidemiology, healthcare utilisation and costs of asthma. 

Methods: We obtained and analysed asthma-relevant data from 27 datasets: these comprised national health surveys for 2010-11, and routine administrative, health and social care datasets for 2011-12; 2011-12 costs were estimated in pounds sterling using economic modelling. 

Results: The prevalence of asthma depended on the definition and data source used. The UK lifetime prevalence of patient-reported symptoms suggestive of asthma was 29.5 % (95 % CI, 27.7-31.3; n = 18.5 million (m) people) and 15.6 % (14.3-16.9, n = 9.8 m) for patient-reported clinician-diagnosed asthma. The annual prevalence of patient-reported clinician-diagnosed-and-treated asthma was 9.6 % (8.9-10.3, n = 6.0 m) and of clinician-reported, diagnosed-and-treated asthma 5.7 % (5.7-5.7; n = 3.6 m). Asthma resulted in at least 6.3 m primary care consultations, 93,000 hospital in-patient episodes, 1800 intensive-care unit episodes and 36,800 disability living allowance claims. The costs of asthma were estimated at least £1.1 billion: 74 % of these costs were for provision of primary care services (60 % prescribing, 14 % consultations), 13 % for disability claims, and 12 % for hospital care. There were 1160 asthma deaths. 

Conclusions: Asthma is very common and is responsible for considerable morbidity, healthcare utilisation and financial costs to the UK public sector. Greater policy focus on primary care provision is needed to reduce the risk of asthma exacerbations, hospitalisations and deaths, and reduce costs.

Predictive Analytics and Decision Support for Heart Failure patients

Thesis (Master's)--University of Washington, 2016-08

A Computer-Aided Decision Support System for Making Locational Decisions, 1990

This report is the product of a first-year research project in the University Transportation Centers Program. This project was carried out by an interdisciplinary research team at The University of Iowa's Public Policy Center. The project developed a computerized system to support decisions on locating facilities that serve rural areas while minimizing transportation costs. The system integrates transportation databases with algorithms that specify efficient locations and allocate demand efficiently to service regions; the results of these algorithms are used interactively by decision makers. The authors developed documentation for the system so that others could apply it to estimate the transportation and route requirements of alternative locations and identify locations that meet certain criteria with the least cost. The system was developed and tested on two transportation-related problems in Iowa, and this report uses these applications to illustrate how the system can be used.

An Empirical Investigation of the Relationships among Climate, Capabilities, and Unit Performance

For the current study, the authors examined the relationships among two dimensions of organizational climate and several indices of individual- and unit-level effectiveness. Specifically, the article proposes that an organization ’s service and training climate would be related to employee capabilities—operationalized in terms of frontline service capabilities and managerial support capabilities—and that such capabilities would be related to unit- level measures of employee turnover and sales growth. Using survey and operational data from 201 management and frontline staff members in 22 units of a national restaurant chain, the results from correlation and regression analyses generally supported the proposed relationships. This study replicates and extends previous research and provides a foundation for future conceptual development and empirical work in this research area.

Effects of age and body mass on development of diving capabilities of gray seal pups: costs and benefits of the postweaning fast

Development of adequate diving capabilities is crucial for survival of seal pups and may depend on age and body size. We tracked the diving behavior of 20 gray seal pups during their first 3 mo at sea using satellite relay data loggers. We employed quantile analysis to track upper limits of dive duration and percentage time spent diving, and lower limits of surface intervals. When pups first left the breeding colony, extreme (ninety-fifth percentile) dive duration and percentage time spent diving were positively correlated with age, but not mass, at departure. Extreme dive durations and percentage time spent diving peaked at [Formula: see text] d of age at values comparable with those of adults, but were not sustained. Greater peaks in extreme percentage time spent diving occurred in pups that had higher initial values, were older at their peak, and were heavier at departure. Pups that were smaller and less capable divers when they left the colony improved extreme dive durations and percentage time spent diving more rapidly, once they were at sea. Minimum survival time correlated positively with departure mass. Pups that were heavier at weaning thus benefitted from being both larger and older at departure, but smaller pups faced a trade-off. While age at departure had a positive effect on early dive performance, departure mass impacted on peak percentage time spent diving and longer-term survival. We speculate that once small pups have attained a minimum degree of physiological development to support diving, they would benefit by leaving the colony when younger but larger to maximize limited fuel reserves, rather than undergoing further maturation on land away from potential food resources, because poor divers may be able to "catch up" once at sea.

Design and implementation of a floating point unit for rigel, a massively parallel accelerator

Scientific applications rely heavily on floating point data types. Floating point operations are complex and require complicated hardware that is both area and power intensive. The emergence of massively parallel architectures like Rigel creates new challenges and poses new questions with respect to floating point support. The massively parallel aspect of Rigel places great emphasis on area efficient, low power designs. At the same time, Rigel is a general purpose accelerator and must provide high performance for a wide class of applications. This thesis presents an analysis of various floating point unit (FPU) components with respect to Rigel, and attempts to present a candidate design of an FPU that balances performance, area, and power and is suitable for massively parallel architectures like Rigel.

Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.

Importance: critical illness results in disability and reduced health-related quality of life (HRQOL), but the optimum timing and components of rehabilitation are uncertain. Objective: to evaluate the effect of increasing physical and nutritional rehabilitation plus information delivered during the post–intensive care unit (ICU) acute hospital stay by dedicated rehabilitation assistants on subsequent mobility, HRQOL, and prevalent disabilities. Design, Setting, and Participants: a parallel group, randomized clinical trial with blinded outcome assessment at 2 hospitals in Edinburgh, Scotland, of 240 patients discharged from the ICU between December 1, 2010, and January 31, 2013, who required at least 48 hours of mechanical ventilation. Analysis for the primary outcome and other 3-month outcomes was performed between June and August 2013; for the 6- and 12-month outcomes and the health economic evaluation, between March and April 2014. Interventions: during the post-ICU hospital stay, both groups received physiotherapy and dietetic, occupational, and speech/language therapy, but patients in the intervention group received rehabilitation that typically increased the frequency of mobility and exercise therapies 2- to 3-fold, increased dietetic assessment and treatment, used individualized goal setting, and provided greater illness-specific information. Intervention group therapy was coordinated and delivered by a dedicated rehabilitation practitioner. Main Outcomes and Measures: the Rivermead Mobility Index (RMI) (range 0-15) at 3 months; higher scores indicate greater mobility. Secondary outcomes included HRQOL, psychological outcomes, self-reported symptoms, patient experience, and cost-effectiveness during a 12-month follow-up (completed in February 2014). Results: median RMI at randomization was 3 (interquartile range [IQR], 1-6) and at 3 months was 13 (IQR, 10-14) for the intervention and usual care groups (mean difference, −0.2 [95% CI, −1.3 to 0.9; P = .71]). The HRQOL scores were unchanged by the intervention (mean difference in the Physical Component Summary score, −0.1 [95% CI, −3.3 to 3.1; P = .96]; and in the Mental Component Summary score, 0.2 [95% CI, −3.4 to 3.8; P = .91]). No differences were found for self-reported symptoms of fatigue, pain, appetite, joint stiffness, or breathlessness. Levels of anxiety, depression, and posttraumatic stress were similar, as were hand grip strength and the timed Up & Go test. No differences were found at the 6- or 12-month follow-up for any outcome measures. However, patients in the intervention group reported greater satisfaction with physiotherapy, nutritional support, coordination of care, and information provision. Conclusions and Relevance: post-ICU hospital-based rehabilitation, including increased physical and nutritional therapy plus information provision, did not improve physical recovery or HRQOL, but improved patient satisfaction with many aspects of recovery.