Development of process control methodology for tracking the quality and safety of pain, agitation and sedation management in critical care units

Objective: To develop sedation, pain, and agitation quality measures using process control methodology and evaluate their properties in clinical practice. Design: A Sedation Quality Assessment Tool was developed and validated to capture data for 12-hour periods of nursing care. Domains included pain/discomfort and sedation-agitation behaviors; sedative, analgesic, and neuromuscular blocking drug administration; ventilation status; and conditions potentially justifying deep sedation. Predefined sedation-related adverse events were recorded daily. Using an iterative process, algorithms were developed to describe the proportion of care periods with poor limb relaxation, poor ventilator synchronization, unnecessary deep sedation, agitation, and an overall optimum sedation metric. Proportion charts described processes over time (2 monthly intervals) for each ICU. The numbers of patients treated between sedation-related adverse events were described with G charts. Automated algorithms generated charts for 12 months of sequential data. Mean values for each process were calculated, and variation within and between ICUs explored qualitatively. Setting: Eight Scottish ICUs over a 12-month period. Patients: Mechanically ventilated patients. Interventions: None. Measurements and Main Results: The Sedation Quality Assessment Tool agitation-sedation domains correlated with the Richmond Sedation Agitation Scale score (Spearman [rho] = 0.75) and were reliable in clinician-clinician (weighted kappa; [kappa] = 0.66) and clinician-researcher ([kappa] = 0.82) comparisons. The limb movement domain had fair correlation with Behavioral Pain Scale ([rho] = 0.24) and was reliable in clinician-clinician ([kappa] = 0.58) and clinician-researcher ([kappa] = 0.45) comparisons. Ventilator synchronization correlated with Behavioral Pain Scale ([rho] = 0.54), and reliability in clinician-clinician ([kappa] = 0.29) and clinician-researcher ([kappa] = 0.42) comparisons was fair-moderate. Eight hundred twenty-five patients were enrolled (range, 59-235 across ICUs), providing 12,385 care periods for evaluation (range 655-3,481 across ICUs). The mean proportion of care periods with each quality metric varied between ICUs: excessive sedation 12-38%; agitation 4-17%; poor relaxation 13-21%; poor ventilator synchronization 8-17%; and overall optimum sedation 45-70%. Mean adverse event intervals ranged from 1.5 to 10.3 patients treated. The quality measures appeared relatively stable during the observation period. Conclusions: Process control methodology can be used to simultaneously monitor multiple aspects of pain-sedation-agitation management within ICUs. Variation within and between ICUs could be used as triggers to explore practice variation, improve quality, and monitor this over time

Understanding nurses’ decision-making when managing weaning from mechanical ventilation: a study of novice and experienced critical care nurses in Scotland and Greece.

Aim and objectives To examine how nurses collect and use cues from respiratory assessment to inform their decisions as they wean patients from ventilatory support. Background Prompt and accurate identification of the patient's ability to sustain reduction of ventilatory support has the potential to increase the likelihood of successful weaning. Nurses' information processing during the weaning from mechanical ventilation has not been well-described. Design A descriptive ethnographic study exploring critical care nurses' decision-making processes when weaning mechanically ventilated patients from ventilatory support in the real setting. Methods Novice and expert Scottish and Greek nurses from two tertiary intensive care units were observed in real practice of weaning mechanical ventilation and were invited to participate in reflective interviews near the end of their shift. Data were analysed thematically using concept maps based on information processing theory. Ethics approval and informed consent were obtained. Results Scottish and Greek critical care nurses acquired patient-centred objective physiological and subjective information from respiratory assessment and previous knowledge of the patient, which they clustered around seven concepts descriptive of the patient's ability to wean. Less experienced nurses required more encounters of cues to attain the concepts with certainty. Subjective criteria were intuitively derived from previous knowledge of patients' responses to changes of ventilatory support. All nurses used focusing decision-making strategies to select and group cues in order to categorise information with certainty and reduce the mental strain of the decision task. Conclusions Nurses used patient-centred information to make a judgment about the patients' ability to wean. Decision-making strategies that involve categorisation of patient-centred information can be taught in bespoke educational programmes for mechanical ventilation and weaning. Relevance to clinical practice Advanced clinical reasoning skills and accurate detection of cues in respiratory assessment by critical care nurses will ensure optimum patient management in weaning mechanical ventilation

'What Foes more dang'rous than too strong Allies?': Anglo-Welsh relations in eighteenth-century London

Prescott, Sarah, ''What Foes more dang'rous than too strong Allies?': Anglo-Welsh relations in eighteenth-century London', The Huntington Library Quarterly (2006) 69 (4) pp.535-554 RAE2008

‘All the places we were not supposed to go’: a case study of formative class and gender habitus in adventure climbing

This paper explores the origins of meaning in adventurous activities. Specifically, the paper reports on a study of 10 adventure climbers in the Scottish mountaineering community. The study explores how formative experiences have influenced engagement in adventure climbing. Work has been done on the phenomenology of adventure and how individuals interpret and find meaning in the activity—this paper goes a step further and asks where do these dispositions come from? Using Bourdieu’s ideas of field, habitus and forms of capital to frame these experiences in the wider social environment, early experiences are identified that, for the subjects of this study, provide a framework for their later adoption of the ‘adventure habitus’. Among these influences are mainstream education, adventure education in particular, as well as broader formative experiences relating to factors such as gender and class. In addition, the study suggests that accounts differ between males and females in terms of their attitudes and dispositions towards adventure. This may relate to their respective experiences as well as expanding opportunities for both males and females. However, while the ‘adventure field’ provides a context where women can develop transformative identities, these are nearly always subject to male validation.

An assessment of international best practice in visitor attraction management: does Scotland really lag behind?

Garrod, Brian, Leask, Anna and Fyall, Alan (2007) An assessment of ?international best practice? in visitor attraction management: does Scotland really lag behind? International Journal of Tourism Research, 9 (1), 21-42. RAE2008

Rainfall infiltration and soil hydrological characteristics below ancient forest, planted forest, and grassland in a temperate northern climate

How rainfall infiltration rate and soil hydrological characteristics develop over time under forests of different ages in temperate regions is poorly understood. In this study, infiltration rate and soil hydrological characteristics were investigated under forests of different ages and under grassland. Soil hydraulic characteristics were measured at different scales under a 250 year old grazed grassland (GL), a six (6 yr) and 48 (48 yr) year old Scots pine (Pinus sylvestris) plantation, remnant 300 year old individual Scots pines (OT) and a 4000 year old Caledonian Forest (AF). In-situ field saturated hydraulic conductivity (Kfs) was measured and visible root:soil area was estimated from soil pits. Macroporosity, pore structure, and macropore connectivity were estimated from X-ray tomography of soil cores, and from water-release characteristics. At all scales the median values for Kfs, root fraction, macro-porosity and connectivity values tended to AF > OT > 48 yr > GL > 6 yr, indicating that infiltration rates and water storage increased with forest age. The remnant Caledonian Forest had a huge range of Kfs (12 to > 4922 mm h-1), with maximum Kfs values 7 to 15 times larger than 48-year-old Scots pine plantation, suggesting that undisturbed old forests, with high rainfall and minimal evapotranspiration in winter, may act as important areas for water storage and sinks for storm rainfall to infiltrate and transport to deeper soil layers via preferential flow. The importance of the development of soil hydrological characteristics under different aged forests is discussed.

Społeczna interpretacja wybranych wczesnośredniowiecznych cmentarzysk rzędowych w perspektywie gender studies i lifecycle analysis

Wydział Historyczny: Instytut Prahistorii

(O)znaki śmierci w polskiej poezji po roku 1956

Wydział Filologii Polskiej i Klasycznej: Instytut Filologii Polskiej

A Catechumenate for the Korean Methodist Church: Ressourcement, Formation and a Response to Secularism and Korean Traditional Religions

Research by Korean sociologists of religion indicates that Korean Protestantism has lost much of the spiritual vitality of preceding generations and that it increasingly shows the influences of Korean shamanism, Neo-Confucianism, and Western secularism and consumerism. Suggestions in the areas of homiletics and Christian social ethics have been offered to help steer the Korean Protestant churches away from these worldviews toward a more biblically-based course. Drawing upon and expanding these earlier studies and proposals, the current work recommends another method for developing a biblically-based, spiritually-revitalized, baptismally-shaped and ministry-committed Protestantism in Korea: a pre-baptismal adult catechumenate, in this case one designed for the context of the Korean Methodist Church. In order to produce a renewed catechumenal structure for Korean Methodism, adult catechumenal processes as well as baptismal theologies and rites are examined and analyzed from three principal sources: the first five centuries of the Christian church, and especially the mystagogical literature of the fourth century; the Roman Catholic Rite of Christian Initiation of Adults developed after the Second Vatican Council; and the United Methodist Church in the United States, both texts officially authorized by the denomination's General Conference and unofficial materials, among them resources for an adult catechumenate in the Come to the Waters series. In addition, previous and current practices of preparation for baptism in the Korean Methodist Church are identified and critiqued. From these findings a set of principles is put forward that guide the proposed catechumenal structure.

The Barretstown experience

The thesis was prompted by a simple clinical observation. Seriously ill children returning from Barretstown Holiday Camp appeared changed. Barretstown ‘magic’ confuses the issue but indicates real and clinically evident transformations. The project sought to understand the experience and place it in a recognisable framework. The data was collected by interviews, observations as camp Paediatrician, memberships of the Child Advisory Committee and the Association’s criteria assessment team, participation in volunteer training and visits to international camps. The research presents evidence that the concepts of rite of passage, graceful mimesis and salutogenesis clarify operative social processes. The passage stages of separation, transition and reaggregation can be identified. Passage rites reorder personal and social upsets to fresh arrangements that facilitate change. Interviews confirm the reordering impact of achievements in play activities. These are challenging experiences closely guided by their Masters of Ceremonies – the Caras. The Cara/camper relationship is crucial and compatible with Girard’s theory of external mimesis. Visits to four camps confirm an inspirational process in contrast to a reported camp with a predetermined formative influence. Charismatic Caras/Councillors inspire playful mimesis and salutogenic transformations. Health is more than correction of pathogenic deficits and restoration of homeostasis. Salutogenic health promotes heterostasis – a desire for optimal experiences underpinned by a sense of coherence and adequate resources. Some evidence is presented that children have an improved sense of coherence after camp, which enables them to cope better with the demands of ill health. The camps enable sick children to up regulate risk taking towards more heterostatic experiences rather than down regulate their expectations. The heterostatic impulse can explain the disability paradox of good quality of life in the presence of severe disability. The salutogenic power of Barretstown can trump the pathogenic effects of childhood cancer and other serious illnesses.

The study of molecular variation in Atlantic salmon (Salmo salar L.) and brown trout (Salmo trutta L.)

Polymorphic microsatellite DNA loci were used here in three studies, one on Salmo salar and two on S. trutta. In the case of S. salar, the survival of native fish and non-natives from a nearby catchment, and their hybrids, were compared in a freshwater common garden experiment and subsequently in ocean ranching, with parental assignment utilising microsatellites. Overall survival of non-natives was 35% of natives. This differential survival was mainly in the oceanic phase. These results imply a genetic basis and suggest local adaptation can occur in salmonids across relatively small geographic distances which may have important implications for the management of salmon populations. In the first case study with S trutta, the species was investigated throughout its spread as an invasive in Newfoundland, eastern Canada. Genetic investigation confirmed historical records that the majority of introductions were from a Scottish hatchery and provided a clear example of the structure of two expanding waves of spread along coasts, probably by natural straying of anadromous individuals, to the north and south of the point of human introduction. This study showed a clearer example of the genetic anatomy of an invasion than in previous studies with brown trout, and may have implications for the management of invasive species in general. Finally, the genetics of anadromous S. trutta from the Waterville catchment in south western Ireland were studied. Two significantly different population groupings, from tributaries in geographically distinct locations entering the largest lake in the catchment, were identified. These results were then used to assign very large rod caught sea trout individuals (so called “specimen” sea trout) back to region of origin, in a Genetic Stock Identification exercise. This suggested that the majority of these large sea trout originated from one of the two tributary groups. These results are relevant for the understanding of sea trout population dynamics and for the future management of this and other sea trout producing catchments. This thesis has demonstrated new insights into the population structuring of salmonids both between and within catchments. While these chapters look at the existence and scale of genetic variation from different angles, it might be concluded that the overarching message from this thesis should be to highlight the importance of maintaining genetic diversity in salmonid populations as vital for their long-term productivity and resilience.

The annual ASCI meeting: does nostalgia have a future?

For many academic physician-scientists, the yearly Tri-Societies meeting of the ASCI, AAP, and AFCR during the 1960s, '70s, and '80s was an annual rite of spring and the focal point of the academic year. In this brief essay, I set down some miscellaneous recollections of these meetings and some thoughts about why they were of such central importance in the careers of those of my generation.

EARLY TWENTIETH CENTURY VIOLA MUSIC FROM ENGLAND AND GERMANY: FROM POST-ROMANTICISM TO MODERNISM

In the early twentieth century, the viola began to gain status as a solo instrument with the appearance in England of the virtuosic violist Lionel Tertis. Because of a lack of music for viola at that time, such English composers as York Bowen, Arnold Bax, Ralph Vaughan Williams, Arthur Bliss and William Walton began to write viola music for Tertis. Meanwhile, in Germany, the well-known composer and virtuosic violinist and violist Paul Hindemith wrote and premiered several viola sonatas and concertos. Viola music became even more developed later with William Primrose, the legendary Scottish violist, and all the works written in the early twentieth century have remained significant in the viola literature. Although this new viola music appeared in both countries during same period, it developed along different lines in each country. Because they were under the influence of earlier periods and traditions, the English composers who associated with Tertis wrote their music in a Romantic style, with expanded harmony, various colors of sound and timbre, and lyrical melodies. Hindemith, as a composer himself, employed a more Modernist style, using atonality and angular melodies, which represented German trends at that time. I have given three recitals, of which the first two were divided between selected English music and German music. Although I originally intended to focus solely on music by Hindemith and music written for Terts, I decided that in order to give a more complete view of the national trends of those two countries, I included Rebecca Clarke's Sonata, Lachrymae by Benjamin Britten (dedicated to William Primrose), and Max Reger's Suite for Viola. Rebecca Clarke was herself a fine violist, and her sonata's Romantic style is also representative of the English trends of viola music. Lachrymae was written with a different concept and shows more modernity than had ever before occurred in England, though it still differs from the modernity of other countries. Max Reger's Suite is in a truly Romantic style, yet it is old fashioned in ways that differ not only from Wagner or Strauss, but also from English music of the period. In my last recital I wished to pay homage to Tertis, with a program consisting entirely of music written for him. For the finale, Arthur Bliss's Viola Sonata was especially chosen because it provides interesting similarities and contrasts with earlier English music in the Romantic style.

Selected Piano Works by Schumann, Liszt, and Brahms Incorporating or Based on Pre-existing Music

This dissertation shows how Schumann, Liszt and Brahms composed piano works based in a variety of ways on other music that already existed. My idea to do this project came through my fascination with Brahms’s Variations on a Theme by Paganini, which was the first piece selected. Brahms composed six sets of variations for solo piano, and I also chose Variations and Fugue on a Theme by Handel. Besides the variations, I included Brahms’s Ballade in D minor, Op. 10 No. 1, based on the Scottish ballad “Edward”. This piece demonstrates that Brahms applied pre-existing music not only in the form of variations, but also in other genres. Among Romantic composers, Schumann and Liszt are two others besides Brahms whose music frequently quotes pre-existing materials. In Schumann’s output, the inspiration from Clara Wieck is significant. The best examples may be the Impromptus Op. 5 and the third movement of the Grand Sonata No. 3, Op. 14, in which Schumann quotes the music by Clara Wieck as the theme of the variations and in the other movements as well to unify the entire piece. In addition, Schumann quotes the old German folk song “Grossvater Tanz” (Grandfather Dance) in the finale of Papillons. The same tune also appears in Carnaval for a programmatic purpose. These two pieces are a clear illustration that Schumann applies pre-existing music, and in addition they represent the spirit of literary reference. Liszt is well known for his superb transformations of other composers’ works into glorious piano compositions. Liszt drew his inspirations from different genres, including both vocal and instrumental music. His ability to turn earlier musical materials into virtuosic solo piano pieces that demonstrate his brilliance in creating imaginative keyboard sounds is remarkable. Among those pieces composed by Liszt, terms such paraphrase, reminiscence, or fantasy frequently appear as titles. I selected two such pieces: Rigoletto: Paraphrase de concert, S. 434 and Rondeau fantastique sur un thème espagnol, S. 252. In addition, Liszt also uses variation form to explore the possibilities of pre-existing themes. The piece I chose to represent this is Variations on the Theme “Weinen, Klagen, Sorgen, Zagen” and Crucifixus from the Mass in B minor by J.S Bach, S.180. This dissertation comprises three piano recitals that were performed in 2010 and 2011 in Ulrich Recital Hall and Gildenhorn Recital Hall of the Clarice Smith Performing Arts Center of the University of Maryland. The recordings are documented on compact discs that are housed within the University of Maryland Library System.

Guidance on interviewing child witnesses in Scotland

The guidance was commissioned from Dr Amina Memon and Lynn Hulse at Aberdeen University. Their work was overseen by a steering group with representatives from the Scottish Executive Justice Department, the Crown Office and Procurator Fiscal Service, NCH Scotland, the Association of Chief Police Officers in Scotland, the Association of Directors of Social Work, the Law Society for Scotland, the Scottish Association of Community Child Health and the Scottish Children’s Reporter Administration. A full list of those involved is given in the Appendix C. pt. 1. Guidance on interviewing child witnesses in Scotland -- pt. 2. Guidance on the questioning of children in court -- pt. 3. Lord Justice-General's memorandum on child witnesses: appendix to Guidance on the questioning of children in court -- pt. 4. Guidance on child witness court familiarisation visits -- pt. 5. Information about child, young and vulnerable adult witnesses to inform decision-making in the legal process: good practice guide -- pt. 6. Code of practice to facilitate the provision of therapeutic support to child witnesses in court proceedings -- pt. 7. Guidance on the conduct of identity parades with child witnesses.