A realistic evaluation of Early Warning Systems and acute care training in Northern Ireland: findings and recommendations

Statement of purpose The purpose of this concurrent session is to present the main findings and recommendations from a five year study evaluating the implementation of Early Warning Systems (EWS) and the Acute Life-threatening Events: Recognition and Treatment (ALERT) course in Northern Ireland. The presentation will provide delegates with an understanding of those factors that enable and constrain successful implementation of EWS and ALERT in practice in order to provide an impetus for change. Methods The research design was a multiple case study approach of four wards in two hospitals in Northern Ireland. It followed the principles of realist evaluation research which allowed empirical data to be gathered to test and refine RRS programme theory [1]. The stages included identifying the programme theories underpinning EWS and ALERT, generating hypotheses, gathering empirical evidence and refining the programme theories. This approach used a variety of mixed methods including individual and focus group interviews, observation and documentary analysis of EWS compliance data and ALERT training records. A within and across case comparison facilitated the development of mid-range theories from the research evidence. Results The official RRS theories developed from the realist synthesis were critically evaluated and compared with the study findings to develop a mid-range theory to explain what works, for whom in what circumstances. The findings of what works suggests that clinical experience, established working relationships, flexible implementation of protocols, ongoing experiential learning, empowerment and pre-emptive management are key to the success of EWS and ALERT implementation. Each concept is presented as ‘context, mechanism and outcome configurations’ to provide an understanding of how the context impacts on individual reasoning or behaviour to produce certain outcomes. Conclusion These findings highlight the combination of factors that can improve the implementation and sustainability of EWS and ALERT and in light of this evidence several recommendations are made to provide policymakers with guidance and direction for future policy development. References: 1. Pawson R and Tilley N. (1997) Realistic Evaluation. Sage Publications; London Type of submission: Concurrent session Source of funding: Sandra Ryan Fellowship funded by the School of Nursing & Midwifery, Queen’s University of Belfast

Early warning systems: problems, pragmatics and potential

Symposium Chair: Dr Jennifer McGaughey

Title: Early Warning Systems: problems, pragmatics and potential

Early Warning Systems (EWS) provide a mechanism for staff to recognise, refer and manage deteriorating patients on general hospital wards. Implementation of EWS in practice has required considerable change in the delivery of critical care across hospitals. Drawing their experience of these changes the authors will demonstrate the problems and potential of using EWS to improve patient outcomes.

The first paper (Dr Jennifer McGaughey: Early Warning Systems: what works?) reviews the research evidence regarding the factors that support or constrain the implementation of Early Warning System (EWS) in practice. These findings explain those processes which impact on the successful achievement of patient outcomes. In order to improve detection and standardise practice National EWS have been implemented in the United Kingdom. The second paper (Catherine Plowright: The implementation of the National EWS in a District General Hospital) focuses on the process of implementing and auditing a National EWS. This process improvement is essential to contribute to future collaborative research and collection of robust datasets to improve patient safety as recommended by the Royal College of Physicians (RCP 2012). To successfully implement NEWS in practice requires strategic planning and staff education. The practical issues of training staff is discussed in the third paper. This paper (Collette Laws-Chapman: Simulation as a modality to embed the use of Early Warning Systems) focuses on using simulation and structured debrief to enhance learning in the early recognition and management of deteriorating patients. This session emphasises the importance of cognitive and social skills developed alongside practical skills in the simulated setting.

Integration of Indicator Alarm Signals for Ecosystem‐Based Fishery Management

We consider the problem of regulating the rate of harvesting a natural resource, taking account of the wider system represented by a set of ecological and economic indicators, given differing stakeholder priorities. This requires objective and transparent decision making to show how indicators impinge on the resulting regulation decision. We offer a new scheme for combining indicators, derived from assessing the suitability of lowering versus not lowering the harvest rate based on indicator values relative to their predefined reference levels. Using the practical example of fisheries management under an “ecosystem approach,” we demonstrate how different stakeholder views can be quantitatively represented by weighting sets applied to these comparisons. Using the scheme in an analysis of historical data from the Celtic Sea fisheries, we find great scope for negotiating agreement among disparate stakeholders.

Passive Intermodulation of Analog and Digital Signals on Transmission Lines with Distributed Nonlinearities: Modelling and Characterization

Passive intermodulation (PIM) often limits the performance of communication systems with analog and digitally-modulated signals and especially of systems supporting multiple carriers. Since the origins of the apparently multiple physical sources of nonlinearity causing PIM are not fully understood, the behavioral models are frequently used to describe the process of PIM generation. In this paper a polynomial model of memoryless nonlinearity is deduced from PIM measurements of a microstrip line with distributed nonlinearity with two-tone CW signals. The analytical model of nonlinearity is incorporated in Keysight Technology’s ADS simulator to evaluate the metrics of signal fidelity in the receive band for analog and digitally-modulated signals. PIM-induced distortion and cross-band interference with modulated signals are compared to those with two-tone CW signals. It is shown that conventional metrics can be applied to quantify the effect of distributed nonlinearities on signal fidelity. It is found that the two-tone CW test provides a worst-case estimate of cross-band interference for two-carrier modulated signals whereas with a three-carrier signal PIM interference in the receive band is noticeably overestimated. The simulated constellation diagrams for QPSK signals demonstrate that PIM interference exhibits the distinctive signatures of correlated distortion and this indicates that there are opportunities for mitigating PIM interference and that PIM interference cannot be treated as noise. One of the interesting results is that PIM distortion on a transmission line results in asymmetrical regrowth of output PIM interference for modulated signals.

Auditory cueing in Parkinson's patients with freezing of gait. What matters most: action-relevance or cue-continuity?

Gait disturbances are a common feature of Parkinson’s disease, one of the most severe being freezing of gait. Sensory cueing is a common method used to facilitate stepping in people with Parkinson’s. Recent work has shown that, compared to walking to a metronome, Parkinson’s patients without freezing of gait (nFOG) showed reduced gait variability when imitating recorded sounds of footsteps made on gravel. However, it is not known if these benefits are realised through the continuity of the acoustic information or the action-relevance. Furthermore, no study has examined if these benefits extend to PD with freezing of gait. We prepared four different auditory cues (varying in action-relevance and acoustic continuity) and asked 19 Parkinson’s patients (10 nFOG, 9 with freezing of gait (FOG)) to step in place to each cue. Results showed a superiority of action-relevant cues (regardless of cue-continuity) for inducing reductions in Step coefficient of variation (CV). Acoustic continuity was associated with a significant reduction in Swing CV. Neither cue-continuity nor action-relevance was independently sufficient to increase the time spent stepping before freezing. However, combining both attributes in the same cue did yield significant improvements. This study demonstrates the potential of using action-sounds as sensory cues for Parkinson’s patients with freezing of gait. We suggest that the improvements shown might be considered audio-motor ‘priming’ (i.e., listening to the sounds of footsteps will engage sensorimotor circuitry relevant to the production of that same action, thus effectively bypassing the defective basal ganglia).

Brain responses and looking behavior during audiovisual speech integration in infants predict auditory speech comprehension in the second year of life

The use of visual cues during the processing of audiovisual (AV) speech is known to be less efficient in children and adults with language difficulties and difficulties are known to be more prevalent in children from low-income populations. In the present study, we followed an economically diverse group of thirty-seven infants longitudinally from 6–9 months to 14–16 months of age. We used eye-tracking to examine whether individual differences in visual attention during AV processing of speech in 6–9 month old infants, particularly when processing congruent and incongruent auditory and visual speech cues, might be indicative of their later language development. Twenty-two of these 6–9 month old infants also participated in an event-related potential (ERP) AV task within the same experimental session. Language development was then followed-up at the age of 14–16 months, using two measures of language development, the Preschool Language Scale and the Oxford Communicative Development Inventory. The results show that those infants who were less efficient in auditory speech processing at the age of 6–9 months had lower receptive language scores at 14–16 months. A correlational analysis revealed that the pattern of face scanning and ERP responses to audiovisually incongruent stimuli at 6–9 months were both significantly associated with language development at 14–16 months. These findings add to the understanding of individual differences in neural signatures of AV processing and associated looking behavior in infants.

A Spiking Neural Network Model of the Medial Superior Olive using Spike Timing Dependent Plasticity for Sound Localisation

Sound localization can be defined as the ability to identify the position of an input sound source and is considered a powerful aspect of mammalian perception. For low frequency sounds, i.e., in the range 270 Hz-1.5 KHz, the mammalian auditory pathway achieves this by extracting the Interaural Time Difference between sound signals being received by the left and right ear. This processing is performed in a region of the brain known as the Medial Superior Olive (MSO). This paper presents a Spiking Neural Network (SNN) based model of the MSO. The network model is trained using the Spike Timing Dependent Plasticity learning rule using experimentally observed Head Related Transfer Function data in an adult domestic cat. The results presented demonstrate how the proposed SNN model is able to perform sound localization with an accuracy of 91.82% when an error tolerance of +/-10 degrees is used. For angular resolutions down to 2.5 degrees , it will be demonstrated how software based simulations of the model incur significant computation times. The paper thus also addresses preliminary implementation on a Field Programmable Gate Array based hardware platform to accelerate system performance.

Joint turbo equalization and cancelation of nonlinear distortion effects in MC-CDMA signals

In this paper, we consider low-PMEPR (Peak-to-Mean Envelope Power Ratio) MC-CDMA (Multicarrier Coded Division Multiple Access) schemes. We develop frequencydomain turbo equalizers combined with an iterative estimation and cancellation of nonlinear distortion effects. Our receivers have relatively low complexity, since they allow FFT-based (Fast Fourier Transform) implementations. The proposed turbo receivers allow significant performance improvements at low and moderate SNR (Signal-to-Noise Ratio), even when a low-PMEPR MC-CDMA transmission is intended.

Spectral analysis of embolic signals

Tese de dout., Engenharia Electrónica e Computação, Faculdade de Ciências e Tecnologia, Univ. do Algarve, 2005

Neural network classification of cerebral embolic signals

The presence of circulating cerebral emboli represents an increased risk of stroke. The detection of such emboli is possible with the use of a transcranial Doppler ultrasound (TCD) system.

Turbo equalization with cancellation of nonlinear distortion effects for CP-Assisted and Zero-Padded MC-CDMA signals

We consider MC-CDMA schemes, with reduced envelope fluctuations. Both CP-assisted (cyclic prefix) and ZP (zero-padded) MC-CDMA schemes are addressed. We develop turbo FDE (frequency-domain equalization) schemes, combined with cancelation of nonlinear distortion effects. The proposed turbo receivers allow significant performance improvements at low and moderate SNR, even when the transmitted signals have reduced envelope fluctuations.

The social brain : how social stimuli are translated into neuroendocrine signals

Tese de doutoramento, Biologia (Ecofisiologia), Universidade de Lisboa, Faculdade de Ciências, 2014