A systematic review of triage-related interventions to improve patient flow in emergency departments

Background Overcrowding in emergency departments is a worldwide problem. A systematic literature review was undertaken to scientifically explore which interventions improve patient flow in emergency departments. Methods A systematic literature search for flow processes in emergency departments was followed by assessment of relevance and methodological quality of each individual study fulfilling the inclusion criteria. Studies were excluded if they did not present data on waiting time, length of stay, patients leaving the emergency department without being seen or other flow parameters based on a nonselected material of patients. Only studies with a control group, either in a randomized controlled trial or in an observational study with historical controls, were included. For each intervention, the level of scientific evidence was rated according to the GRADE system, launched by a WHO-supported working group. Results The interventions were grouped into streaming, fast track, team triage, point-of-care testing (performing laboratory analysis in the emergency department), and nurse-requested x-ray. Thirty-three studies, including over 800,000 patients in total, were included. Scientific evidence on the effect of fast track on waiting time, length of stay, and left without being seen was moderately strong. The effect of team triage on left without being seen was relatively strong, but the evidence for all other interventions was limited or insufficient. Conclusions Introducing fast track for patients with less severe symptoms results in shorter waiting time, shorter length of stay, and fewer patients leaving without being seen. Team triage, with a physician in the team, will probably result in shorter waiting time and shorter length of stay and most likely in fewer patients leaving without being seen. There is only limited scientific evidence that streaming of patients into different tracks, performing laboratory analysis in the emergency department or having nurses to request certain x-rays results in shorter waiting time and length of stay.

The Potential Of Kohonen Method For Classifying Rivers Focused On Regional Environmental Flow Determination With ELOHA

This article highlights the potential benefits that the Kohonen method has for the classification of rivers with similar characteristics by determining regional ecological flows using the ELOHA (Ecological Limits of Hydrologic Alteration) methodology. Currently, there are many methodologies for the classification of rivers, however none of them include the characteristics found in Kohonen method such as (i) providing the number of groups that actually underlie the information presented, (ii) used to make variable importance analysis, (iii) which in any case can display two-dimensional classification process, and (iv) that regardless of the parameters used in the model the clustering structure remains. In order to evaluate the potential benefits of the Kohonen method, 174 flow stations distributed along the great river basin “Magdalena-Cauca” (Colombia) were analyzed. 73 variables were obtained for the classification process in each case. Six trials were done using different combinations of variables and the results were validated against reference classification obtained by Ingfocol in 2010, whose results were also framed using ELOHA guidelines. In the process of validation it was found that two of the tested models reproduced a level higher than 80% of the reference classification with the first trial, meaning that more than 80% of the flow stations analyzed in both models formed invariant groups of streams.

A Study On The Flow Characteristics Influenced By Hydraulic Structure At A Channel Junction

Natural riversare consisting of various networks as junction andstreams. And sediment and erosion are occurred by specific stream condition. When flood season,large discharge flew in the river and river bed changed by high flow velocity. Especially junction area’s flow characteristics are very complex. The purpose of this study is to analyze the flow characteristics in channel junction, which are most influenced by large discharge like flooding and input water from tributary. We investigate the flow characteristics by using hydrodynamics and transport module in MIKE 3 FM. MIKE 3 FM model was helpful tool to analysis 3D hydrodynamics, erosion and sediment effect from channel bed. We analyze flow characteristics at channel junction. Also we consider hydraulic structures like a bridge pier which is influencing flow characteristics like a flow velocity, water level, erosion and scour depth in channel bed. In the model, we controlled discharge condition according to Froude Number and reflect various grain diameter size and flow ratio change in main stream and tributary. In the result, flow velocity, water level, erosion and sediment depth are analyzed. Additionally, we suggest a these result relationship with equations. This study will help the understand flow characteristics and influence of hydraulic structure in channel junction. Acknowledgments This research was supported by a grant (12-TI-C01) from Advanced Water Management Research Program funded by Ministry of Land, Infrastructure and Transport of Korean government.

Uma experiência na utilizacao do vbm (value based management) como ferramenta de desenvolvimento de estratégias de negócio

Esta tese baseia-se na experiência adquirida com a participação num projeto de implantação do conceito de Value Based Management em urna empresa multinacional de bens de consumo. A maior parte do material aqui comentado foi colhido durante o primeiro semestre do ano de 1995 - período em que durou o projeto - e parte durante duas semanas no início do ano, nas quais participei em Londres de um treinamento intensivo, ministrado por uma conceituada firma de consultoria internacional, sobre a teoria e prática deste novo conceito, juntamente com diversos participantes de outros projetos VBM ao redor do mundo como Estados Unidos, França, Itália, Alemanha, Inglaterra, Espanha, entre outros

Study of the innovation management process in the development of a discontinuous product case: Motorola RAZR V3

This study will collaborate by bringing some detailed analysis and findings on a special case study of a discontinuous product development process, trying to answer how the discontinuous product development process takes place and the main factors that influence this process. Additionally, it tried to explore some explanations for the difficulties generally faced by the companies to sustain innovation. The case is about the Motorola cell phone RAZR V3, launched in 2004. RAZR V3 was noted by industry experts as game-changing feat of design and engineering, selling more than 110 million units by end of 2008 and recognized as one of the fastest selling products in the industry. The study uses a single case methodology, which is appropriate given the access to a phenomenon that happened inside corporate dominium and it is not easily accessed for academic studies, besides being a rare case of success in the cellular phone industry. In order to magnify the understanding of the phenomenon, the exploration was extended to contrast the RAZR development process and the standard product development process in Motorola. Additionally, it was integrated a longitudinal reflection of the company product development evolution until the next breakthrough product hitting the cellular phone industry. The result of the analysis shows that discontinuous products do not fit well traditional product development process (in this case, stage-gate). This result reinforces the results obtained on previous studies of discontinuous product development conducted by other authors. Therefore, it is clear that the dynamics of discontinuous product development are different from the continuous product development, requiring different treatment to succeed. Moreover, this study highlighted the importance of the management influence in all the phases of the process as one of the most important factors, suggesting a key component to be carefully observed in future researches. Some other findings of the study that were considered very important for a discontinuous product development process: have champions (who believe and protect the project) and not only one champion; create a right atmosphere to make flow the creative process; question paradigms to create discontinuous products; simple guiding light to focus the team; company culture that accepts and knows how to deal with risks; and undoubtedly, have a company strategy that understands the different dynamics of continuous and discontinuous product development processes and treat them accordingly.

Public debt management, monetary policy and financial institutions

Despite the large size of the Brazilian debt market, as well the large diversity of its bonds, the picture that emerges is of a market that has not yet completed its transition from the role it performed during the megainflation years, namely that of providing a liquid asset that provided positive real returns. This unfinished transition is currently placing the market under severe stress, as fears of a possible default from the next administration grow larger. This paper analyzes several aspects pertaining to the management of the domestic public debt. The causes for the extremely large and fast growth ofthe domestic public debt during the seven-year period that President Cardoso are discussed in Section 2. Section 3 computes Value at Risk and Cash Flow at Risk measures for the domestic public debt. The rollover risk is introduced in a mean-variance framework in Section 4. Section 5 discusses a few issues pertaining to the overlap between debt management and monetary policy. Finally, Section 6 wraps up with policy discussion and policy recommendations.

Logística e supply chain management: parte I

Professor e aluno da GV, professora convidada e profissional de mercado falam de logística e supply chain management

Logística e supply chain management: parte II

Professor e aluno da GV, professora convidada e profissional de mercado falam de logística e supply chain management

Effects of rainfall on water quality in six sequentially disposed fishponds with continuous water flow

O estudo foi efetuado durante o período de chuva (dezembro-fevereiro) em seis viveiros de produção semi-intensiva de peixes, a fim de avaliar o efeito da chuva na qualidade da água de viveiros que apresentam fluxo contínuo de água, a qual é passada de um viveiro para outro sem tratamento prévio. Foram amostrados oito pontos de coleta nas saídas dos viveiros. O viveiro P1 (próximo à nascente) apresentou as menores concentrações físicas e químicas da água e as maiores no viveiro P4 (considerado um ponto crítico recebendo material alóctone proveniente de outros viveiros e do escoamento do setor de criação de rãs). A disposição seqüencial dos viveiros estudados promoveu aumento nas concentrações dos nutrientes, clorofila-a e condutividade. As chuvas características desta época do ano aumentaram o fluxo de água nos viveiros e conseqüentemente, carreando material particulado e dissolvido de um viveiro para outro e, promovendo um aumento das variáveis limnológicas em direção do P3 ao P6. Os resultados sugerem que a chuva no período de estudo afetou positivamente a qualidade da água dos viveiros estudados, porém, como os sistemas analisados estão dispostos em distribuição seqüencial e escoamento constante da água de viveiros e tanques paralelos sem tratamento prévio, cuidados devem ser averiguados para que o aumento do fluxo de água provocado pelas chuvas não tenha efeito adverso nos viveiros estudados.

Characterization and evaluation of the impact of feed management on the effluents of Nile tilapia (Oreochromis niloticus) culture

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Limnology of Macrobrachium amazonicum grow-out ponds subject to high inflow of nutrient-rich water and different stocking and harvest management

We evaluated the water characteristics and particle sedimentation in Macrobrachium amazonicum (Heller 1862) grow-out ponds supplied with a high inflow of nutrient-rich water. Prawns were subject to different stocking and harvesting strategies: upper-graded juveniles, lower-graded juveniles, non-graded juveniles + selective harvesting and traditional farming (non-grading juveniles and total harvest only). Dissolved oxygen, afternoon N-ammonia and N-nitrate and soluble orthophosphate were lower in the ponds in comparison with inflow water through the rearing cycle. Ponds stocked with the upper population fraction of graded prawns showed higher turbidity, total suspended solids and total Kjeldahl nitrogen than the remaining treatments. An increase in the chemical oxygen demand:biochemical oxygen demand ratio from inlet (4.9) to pond (7.1-8.0) waters indicated a non-readily biodegradable fraction enhancement in ponds. The sedimentation mean rate ranged from 0.08 to 0.16 mm day(-1) and sediment contained >80% of organic matter. The major factors affecting pond ecosystem dynamic were the organic load (due to primary production and feed addition) and bioturbation caused by stocking larger animals. Data suggest that M. amazonicum grow-out in ponds subjected to a high inflow of nutrient-rich water produce changes in the water properties, huge accumulation of organic sediment at the pond bottom and non-readily biodegradable material in the water column. However, the water quality remains suitable for aquaculture purposes. Therefore, nutrient-rich waters, when available, may represent a source of unpaid nutrients, which may be incorporated into economically valued biomass if managed properly.

Dunging gutters filled with fresh water in finishing barns had no effect on the prevalence of Salmonella enterica on Brazilian swine farms

Our aim was to assess the importance of dunging gutters filled with water in finishing barns for the prevalence of pigs shedding Salmonella enterica. Some finishing barns in Brazil are provided with a dunging-gutter system which consists of a continuous water flow at the back of solid-floored adjacent pens. Because there is transfer of faecal material between adjacent pens by water in this system and the faecal-oral route of transmission is so important for enteric pathogens, we tested the hypothesis that the presence of this kind of dunging-gutter system in finishing barns affects the prevalence of slaughter-age pigs shedding salmonella organisms in their faeces. The cross-sectional study was conducted on six farms each having barns with and barns without a dunging-gutter system. Breeding, management, nutritional and seasonal factors were similar in both barns on each farm. The two systems did not differ in prevalence of pigs shedding salmonella organisms. Five S. enterica scrotypes were isolated: S. Agona, S. Javiana, S. Rissen, S. Sandiego and S. Senftenberg. (C) 2002 Elsevier B.V. B.V. All rights reserved.

Topographical characteristics and evaluating water quality in watershed management

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Atenção à saúde mental na Estratégia Saúde da Família no Município de Parnamirim/RN: opinião dos profissionais, dos portadores de transtornos mentais e seus acompanhantes

This study aims to analyze and compare the opinion of professionals, managers and users about the mental health care in the Family Health Strategy (FHS). It is characterized as an Operations Research or Health System Research with a cross-sectional design and a descriptive quantitative nature. The study was developed from the application of the Opinion Measurement Scale allied to techniques of observation and structured interview in the city of Parnamirim / RN. The sample consists of 409 subjects, 209 professionals of the Family Health Strategy, 30 of the Oral Health Strategy, 19 of the Family Health Support Center, 24 directors of Basic Health Units, plus 68 users with mental disorders and 59 caregivers, respecting the ethical parameters of Resolution 196/96 of the National Health Council, trial registration number: CAAE 0003.0.051.000-11. Quantitative data were submitted to the Epi-info 3.5.2 for analysis. The network of mental health in Parnamirim involves the flow between the FHS, Psychosocial Care Centers, clinics and hospitals, having as main barriers the fragility of the referral and counter-referral system, of the municipal health conferences, of the FHS teams by the limitations in material and human resources as well as the population´s lack of acknowledge about the organization of the mental health network, issues that affect the integral attention. Even though the FHS professionals recognize the importance of their actions, they question their role in mental health care, experiencing difficulties in accessing psychiatric services (76.5%). Although most agree that the mentally ill is best treated in the family than in hospital (65.2%), the community health workers were the predominant category in the partial or total disagreement of this statement (40.8%), who is the professional in greater contact with the family. Nevertheless the caregivers miss the support of the FHS as the main focus of attention is on revenue control. The views of professionals, mental patients and caregivers converged in several statements, showing the main weaknesses to be focused by the mental health network of the city, as the perceptions that: (a) physical strength is needed to take care of mental patients for its tendency to aggression, requiring it to stay in the sanatorium for representing danger to society, (b) only a psychiatrist can help the person with emotional problems, (c) the user of alcohol and drugs does not necessarily develop mental illness, (d) the access barriers and doubts about the quality of psychiatric services, (e) caring of a mental health patient does not bring suffering to professionals. Therefore, the commitment to consensus building, monitoring and evaluation of the network are important mechanisms for an effective management system, reflecting in the importance of strengthening the health conferences and approximating different institutions. The results reinforce the importance of strengthening primary care through programs of continuing education focusing on the actions and functions of professionals in accordance with its competences and duties what contribute to the organization and response of mental health care, favoring user´s care and the promotion of family health

Utilização de soluções business-to-business (B2B) no segmento downstream da cadeia de suprimentos de uma distribuidora de combustíveis

The pursuit of competitive advantage is lobbying organizations to strategically plan the use of their material, human, technological and financial resources, so that it s possible to add value to the product, even when it is considered a commodity. The scenario for this planning should not be limited to the company in question, but cover an entire supply chain, which is composed of several organizations which have common goals of growth and sustainability of the market. They should form trade links, integrating the chains of individual values, in a perspective of value system. In this supply chain there is a flow of services, payments and information, as products well as. The training of these links can be supported by the adoption of a set of information technology, here called solutions business-to-business (B2B), which will be responsible for the production, storage and distribution of relevant information to business transactions between the companies involved. On this view, this thesis aims to describe the B2B solutions adopted in the downstream segment of the supply chain of a distributor of fuel and the nature of these technologies as well as their impact on the creation of value for business and optimization of the relationship between companies. This is a case study on a national distributor of fuels, from a model of research produced under the influence of theories of integrated logistics system and value of Michael Porter. The analyses came to the conclusion that information technology is perceived as an essential tool to the operation of all activities carried out by the company. Among them, at was also brought the key activities of integrated logistics: administration of applications, inventory management, management transport and customer services, which were highlighted in this study. It was also noticed that even these activities are, in principle, purely operational; they all had in the adoption of strategies for leadership in cost or differentiation, supported by B2B solutions identified, making it more conducive to business and direct customer, the clinic reseller of fuel, to obtain value and benefits of this market segment as competitive