Decisional responsibility for mechanical ventilation and weaning: an international survey

Introduction: Optimal management of mechanical ventilation and weaning requires dynamic and collaborative decision making to minimize complications and avoid delays in the transition to extubation. In the absence of collaboration, ventilation decision making may be fragmented, inconsistent, and delayed. Our objective was to describe the professional group with responsibility for key ventilation and weaning decisions and to examine organizational characteristics associated with nurse involvement.

Methods: A multi-center, cross-sectional, self-administered survey was sent to nurse managers of adult intensive care units (ICUs) in Denmark, Germany, Greece, Italy, Norway, Switzerland, Netherlands and United Kingdom (UK). We summarized data as proportions (95% confidence intervals (CIs)) and calculated odds ratios (OR) to examine ICU organizational variables associated with collaborative decision making.

Results: Response rates ranged from 39% (UK) to 92% (Switzerland), providing surveys from 586 ICUs. Interprofessional collaboration (nurses and physicians) was the most common approach to initial selection of ventilator settings (63% (95% CI 59 to 66)), determination of extubation readiness (71% (67 to 75)), weaning method (73% (69 to 76)), recognition of weaning failure (84% (81 to 87)) and weaning readiness (85% (82 to 87)), and titration of ventilator settings (88% (86 to 91)). A nurse-to-patient ratio other than 1:1 was associated with decreased interprofessional collaboration during titration of ventilator settings (OR 0.2, 95% CI 0.1 to 0.6), weaning method (0.4 (0.2 to 0.9)), determination of extubation readiness (0.5 (0.2 to 0.9)) and weaning failure (0.4 (0.1 to 1.0)). Use of a weaning protocol was associated with increased collaborative decision making for determining weaning (1.8 (1.0 to 3.3)) and extubation readiness (1.9 (1.2 to 3.0)), and weaning method (1.8 (1.1 to 3.0)). Country of ICU location influenced the profile of responsibility for all decisions. Automated weaning modes were used in 55% of ICUs.

Conclusions: Collaborative decision making for ventilation and weaning was employed in most ICUs in all countries although this was influenced by nurse-to-patient ratio, presence of a protocol, and varied across countries. Potential clinical implications of a lack of collaboration include delayed adaptation of ventilation to changing physiological parameters, and delayed recognition of weaning and extubation readiness resulting in unnecessary prolongation of ventilation.

How Outcomes Are Defined in Clinical Trials of Mechanically Ventilated Adults and Children

Systematic reviews have considerable potential to provide evidence-based data to aid clinical decision-making. However, there is growing recognition that trials involving mechanical ventilation lack consistency in the definition and measurement of ventilation outcomes, creating difficulties in combining data for meta-analyses. To address the inconsistency in outcome definitions, international standards for trial registration and clinical trial protocols published recommendations, effectively setting the “gold standard” for reporting trial outcomes. In this Critical Care Perspective, we review the problems resulting from inconsistent outcome definitions and inconsistent reporting of outcomes (outcome sets). We present data highlighting the variability of the most commonly reported ventilation outcome definitions. Ventilation outcomes reported in trials over the last 6 years typically fall into four domains: measures of ventilator dependence; adverse outcomes; mortality; and resource use. We highlight the need, first, for agreement on outcome definitions and, second, for a minimum core outcome set for trials involving mechanical ventilation. A minimum core outcome set would not restrict trialists from measuring additional outcomes, but would overcome problems of variability in outcome selection, measurement, and reporting, thereby enhancing comparisons across trials.

Risk, Recovery and Capacity: Competing or Complementary Approaches to Mental Health Social Work

Mental health social workers have a central role in providing support to people with mental health problems and in the use of coercion aimed at dealing with risk. Mental health services have traditionally focused on monitoring symptoms and ascertaining the risks people may present to themselves and/or others. This well-intentioned but negative focus on deficits has contributed to stigma, discrimination and exclusion experienced by service users. Emerging understandings of risk also suggest that our inability to accurately predict the future makes risk a problematic foundation for compulsory intervention. It is therefore argued that alternative approaches are needed to make issues of power and inequality transparent. This article focuses on two areas of practice: the use of recovery based approaches, which promote supported decision making and inclusion; and the assessment of a person’s ability to make decisions, their mental capacity, as a less discriminatory gateway criterion than risk for compulsory intervention.

Challenging the cancer molecular stratification dogma: Intratumoral heterogeneity undermines consensus molecular subtypes and potential diagnostic value in colorectal cancer

Purpose:
A number of independent gene expression profiling studies have identified transcriptional subtypes in colorectal cancer (CRC) with potential diagnostic utility, culminating in publication of a CRC Consensus Molecular Subtype classification. The worst prognostic subtype has been defined by genes associated with stem-like biology. Recently, it has been shown that the majority of genes associated with this poor prognostic group are stromal-derived. We investigated the potential for tumor misclassification into multiple diagnostic subgroups based on tumoral region sampled.

Experimental Design:
We performed multi-region tissue RNA extraction/transcriptomic analysis using Colorectal Specific Arrays on invasive front, central tumor and lymph node regions selected from tissue samples from 25 CRC patients.

Results:
We identified a consensus 30 gene list which represents the intratumoral heterogeneity within a cohort of primary CRC tumors. Using a series of online datasets, we showed that this gene list displays prognostic potential (HR=2.914 (CI 0.9286-9.162) in stage II/III CRC patients, but in addition we demonstrated that these genes are stromal derived, challenging the assumption that poor prognosis tumors with stem-like biology have undergone a widespread Epithelial Mesenchymal Transition (EMT). Most importantly, we showed that patients can be simultaneously classified into multiple diagnostically relevant subgroups based purely on the tumoral region analysed.

Conclusions:
Gene expression profiles derived from the non-malignant stromal region can influence assignment of CRC transcriptional subtypes, questioning the current molecular classification dogma and highlighting the need to consider pathology sampling region and degree of stromal infiltration when employing transcription-based classifiers to underpin clinical decision-making in CRC.

Adding value to performance measurement by using system dynamics and multicriteria analysis

Tese de dout., Filosofia, Department of Management Science, University of Strathclyde, 2004

A study of ethical decision-making in hypothetical scenarios by secondary school principals /

The purpose of the study,was to investigate the ways in which secondary school principals make decisions that have an ethical dimension, and the reasons they use to justify their choices. The ethical principles and concepts, as well as the scenarios, were adapted from The Ethics ofSchool Administration by Strike, Haller, and Soltis (1998). In this study, 32 secondary principals from a school board in Ontario were asked to complete a descriptive survey which was designed to have principals make administrative decisions in response to 5 hypothetical scenarios. The open-ended questions were expected to elicit responses that were reflective of the principals' actual decision-making strategies. The survey also required them to justify and explain their reasons for each decision. The data were analyzed and 4 major categories ofjustifications emerged: pedagogy, legalism, moral code, and democracy. The results indicate that the decisions made by principals are grounded in various perspectives. While the data did not indicate any explicit knowledge of ethical principles and concepts, the principals' responses suggest sound and valid reasoning for their decision making, addressing the principles and concepts from a variety of viewpoints and using diverse justifications.

Conceção de um modelo de avaliação do desempenho adequado à gestão dos recursos humanos da Santa Casa da Misericórdia da Marinha Grande

O terceiro Setor ocupa um lugar central na governação, na generalidade das sociedades contemporâneas. As novas exigências de competitividade, impõem também às Misericórdias, uma reestruturação dos processos de gestão, de forma a ser possível alinhar a missão organizacional com o nível de desempenho esperado. Pretende-se identificar um modelo de avaliação do desempenho dos colaboradores da Santa Casa da Misericórdia da Marinha Grande, que permita adequar o desempenho individual, às exigências funcionais e da Instituição. Foi adotada como base científica, a Metodologia Multicritério de Apoio à Decisão (MMAD), com vista ao alcance de uma maior à transparência e clareza das avaliações, e ainda, à obtenção de dados que permitam uma melhorada gestão do desempenho (relação dos resultados da avaliação, com as politicas de recrutamento, seleção e formação), gerando assim um modelo, em que todos possam confiar; O autor deste estudo pretende extrapolar o modelo identificado, a outras Misericórdias do País.

The use of a multiple criteria decision analysis to evaluate the effectiveness of landscape and habitat enhancement mechanisms: an example from the South Downs

A range of funding schemes and policy instruments exist to effect enhancement of the landscapes and habitats of the UK. While a number of assessments of these mechanisms have been conducted, little research has been undertaken to compare both quantitatively and qualitatively their relative effectiveness across a range of criteria. It is argued that few tools are available for such a multi-faceted evaluation of effectiveness. A form of Multiple Criteria Decision Analysis (MCDA) is justified and utilized as a framework in which to evaluate the effectiveness of nine mechanisms in relation to the protection of existing areas of chalk grassland and the creation of new areas in the South Downs of England. These include established schemes, such as the Countryside Stewardship and Environmentally Sensitive Area Schemes, along with other less common mechanisms, for example, land purchase and tender schemes. The steps involved in applying an MCDA to evaluate such mechanisms are identified and the process is described. Quantitative results from the comparison of the effectiveness of different mechanisms are presented, although the broader aim of the paper is that of demonstrating the performance of MCDA as a tool for measuring the effectiveness of mechanisms aimed at landscape and habitat enhancement.

Key performance indicators (KPIs) and priority setting in using the multi-attribute approach for assessing sustainable intelligent buildings

The main objectives of this paper are to: firstly, identify key issues related to sustainable intelligent buildings (environmental, social, economic and technological factors); develop a conceptual model for the selection of the appropriate KPIs; secondly, test critically stakeholder's perceptions and values of selected KPIs intelligent buildings; and thirdly develop a new model for measuring the level of sustainability for sustainable intelligent buildings. This paper uses a consensus-based model (Sustainable Built Environment Tool- SuBETool), which is analysed using the analytical hierarchical process (AHP) for multi-criteria decision-making. The use of the multi-attribute model for priority setting in the sustainability assessment of intelligent buildings is introduced. The paper commences by reviewing the literature on sustainable intelligent buildings research and presents a pilot-study investigating the problems of complexity and subjectivity. This study is based upon a survey perceptions held by selected stakeholders and the value they attribute to selected KPIs. It is argued that the benefit of the new proposed model (SuBETool) is a ‘tool’ for ‘comparative’ rather than an absolute measurement. It has the potential to provide useful lessons from current sustainability assessment methods for strategic future of sustainable intelligent buildings in order to improve a building's performance and to deliver objective outcomes. Findings of this survey enrich the field of intelligent buildings in two ways. Firstly, it gives a detailed insight into the selection of sustainable building indicators, as well as their degree of importance. Secondly, it tesst critically stakeholder's perceptions and values of selected KPIs intelligent buildings. It is concluded that the priority levels for selected criteria is largely dependent on the integrated design team, which includes the client, architects, engineers and facilities managers.

Are power calculations useful? A multicentre neuroimaging study

There are now many reports of imaging experiments with small cohorts of typical participants that precede large-scale, often multicentre studies of psychiatric and neurological disorders. Data from these calibration experiments are sufficient to make estimates of statistical power and predictions of sample size and minimum observable effect sizes. In this technical note, we suggest how previously reported voxel-based power calculations can support decision making in the design, execution and analysis of cross-sectional multicentre imaging studies. The choice of MRI acquisition sequence, distribution of recruitment across acquisition centres, and changes to the registration method applied during data analysis are considered as examples. The consequences of modification are explored in quantitative terms by assessing the impact on sample size for a fixed effect size and detectable effect size for a fixed sample size. The calibration experiment dataset used for illustration was a precursor to the now complete Medical Research Council Autism Imaging Multicentre Study (MRC-AIMS). Validation of the voxel-based power calculations is made by comparing the predicted values from the calibration experiment with those observed in MRC-AIMS. The effect of non-linear mappings during image registration to a standard stereotactic space on the prediction is explored with reference to the amount of local deformation. In summary, power calculations offer a validated, quantitative means of making informed choices on important factors that influence the outcome of studies that consume significant resources.

Interlink decision making index (IDMI) -- a simple tool/concept to assist decision making for sustainability Part 1: definition of IDMI

There is an apparent gap between the LCA or other assessment's outcomes and its effective application in the decision making process. It is needed to provide to the decision makers a simple, less human interfered mechanism that integrates all the key criteria (environmental, economic, technical and safety etc.). The proposed index: Interlink Decision Making Index (IDMI) has all these features: simple, interlink (all criteria) and automatically and quantified influence of critical criteria (ie. no human weighting needed) and is able to assist the multi-criteria decision making for sustainability based on the outcomes of specific assessments (eg. LCA, ElA etc.). The index represents a pure numerical value and does not necessarily have any physical meanings, but it reflects the total merits of a particular option once the normal decision making criteria and (up to two) critical criteria (CC) have been chosen. Then, without arbitrarily weighting process, the comparison and selection of the best possible option, ie. decision can be made based on the derived IDMI results. Two hypothetical examples are presented in part 2 of the paper to demonstrate the application of the IDMI concept and it's differences with the traditional "tabular method" in the decision making process.

Interlink decision making index (IDMI) : a simple tool/concept to assist decision making for sustainability part 2 : calculation and examples of IDMI

There is an apparent gap between the LCA or other assessment's outcomes and its effective application in the decision making process. It is needed to provide to the decision makers a simple, less human interfered mechanism that integrates all the key criteria (environmental, economic, technical and safety etc.). The proposed index: Interlink Decision Making Index (IDMI) has all these features: simple, interlink (all criteria) and automatically and quantified influence of critical criteria (ie. no human weighting needed) and is able to assist the multi-criteria decision making for sustainability based on the outcomes of specific assessments (eg. LCA, BIA etc.). The index represents a pure numerical value and does not necessarily have any physical meanings, but it reflects the total merits of a particular option once the normal decision making criteria and (up to two) critical criteria (Ce) have been chosen. Then, without arbitrarily weighting process, the comparison and selection of the best possible option, ie. decision can be made based on the derived IDMI results. Two hypothetical examples are presented in the part 2 of the paper to demonstrate the application of the IDMI concept and it's differences with the traditional "tabular method" in the decision making process.

Morals, rights and practice in the human services : effective and fair decision-making in health, social care and criminal justice

Provides a synthesis of human rights theory and human services practice and offers a rights based model to aid professional decision making and practice.

A two-stage dynamic group decision making method for processing ordinal information

In group decision making (GDM) problems, ordinal data provide a convenient way of articulating preferences from decision makers (DMs). A number of GDM models have been proposed to aggregate such kind of preferences in the literature. However, most of the GDM models that handle ordinal preferences suffer from two drawbacks: (1) it is difficult for the GDM models to manage conflicting opinions, especially with a large number of DMs; and (2) the relationships between the preferences provided by the DMs are neglected, and all DMs are assumed to be of equal importance, therefore causing the aggregated collective preference not an ideal representative of the group's decision. In order to overcome these problems, a two-stage dynamic group decision making method for aggregating ordinal preferences is proposed in this paper. The method consists of two main processes: (i) a data cleansing process, which aims to reduce the influence of conflicting opinions pertaining to the collective decision prior to the aggregation process; as such an effective solution for undertaking large-scale GDM problems is formulated; and (ii) a support degree oriented consensus-reaching process, where the collective preference is aggregated by using the Power Average (PA) operator; as such, the relationships of the arguments being aggregated are taken into consideration (i.e., allowing the values being aggregated to support each other). A new support function for the PA operator to deal with ordinal information is defined based on the dominance-based rough set approach. The proposed GDM model is compared with the models presented by Herrera-Viedma et al. An application related to controlling the degradation of the hydrographic basin of a river in Brazil is evaluated. The results demonstrate the usefulness of the proposed method in handling GDM problems with ordinal information.

Evaluation of a knowledge translation and exchange platform to advance non-communicable disease prevention

Coordinated systems are required to ensure evidence-informed practice and evaluation of community-based interventions (CBIs). Knowledge translation and exchange (KTE) strategies show promise, but these require evaluation. This paper describes implementation and evaluation of COOPS, a national KTE platform to support best practice in obesity prevention CBIs. A logic model guides KTE activities including knowledge brokering, networking, tailored communications, training, and needs assessments. A mixed-methods evaluation includes communications data, knowledge brokering database, annual survey of CBIs, pre- and post-event questionnaires, interviews, social network analysis, and case studies. This evaluation will contribute to understanding the process of implementing a KTE platform with CBIs and its reach, quality and effectiveness.