Improving the outcomes of foot and ankle surgery through the audit cycle : a case study

The direct costs of managing adverse outcomes from Australian health care are estimated to be $2 billion. The audit cycle is considered an important tool to assist in the preventive management of adverse outcomes.Australian guidelines for audit cycle design allow for comparison of data sets derived from similar surgical specialities. However a lack of data set standardisation inhibits meaningful comparisons of foot and ankle surgical audits. This research will assist development of a best practice model for auditing foot and ankle surgery. Data derived from this model will improve the safety and quality of foot and ankle surgery. The preliminary phase of this process is to identify and understand the attitudes and behaviours of how and why surgeons participate in the audit cycle. A descriptive embedded multiple case study research design is planned to provide an intense focus on a single phenomenon (the audit cycle) within its real life context (clinical governance). The measures to be included in the case study have been identified by the Balanced Patient Safety Measurement Framework. These include: audit and peer review activity, provider attitudes to patient safety, safety learning, action and performance. A purposive sample of 6 to 8 surgeons (units of analysis) from 3 to 4 specialities (cases) will undergo semi-structured interview. This will investigate: current audit tools and processes; attitudes; and behaviours of surgeons to the audit cycle. Similarities in and differences between the units of analysis will indicate which identified measures function as barriers or enablers of the audit cycle. Reliability and validity (external and construct) will be assessed using established methods for case studies. The descriptive embedded multiple case study will reveal how and why foot and ankle surgeons participate in the audit cycle. This will inform further research to improve the outcomes of foot and ankle surgery through development of an audit tool.

Effects of driver familiarity and prolonged or intermittent right-side failure on level crossing safety

This paper investigates the adverse effects of familiarity and human factors issues associated with the reliability of low-cost warning devices at level crossings. The driving simulator study featured a repetitive, low workload, monotonous driving task in which there were no failures of the level crossing (control) or prolonged or intermittent right-side failures (where the device reverts to a safe failure mode). The results of the experiment provided mixed support for the familiarity hypothesis. Four of the 23 participants collided with the train when it first appeared on trial 10 but safety margins increased from the first train to the next presentation of a train (trial 12). Contrary to expectations, the safety margins decreased with repeated right-side failure only for the intermittent condition. The limited head movement data showed that participants in the prolonged failure condition were more likely to turn their head to check for trains in the right-side failure trials than in earlier trials where there was no signal and no train. Few control participants turned their head to check for trains when no signal was presented. This research highlights the need to consider repetitive tasks and workload in experimental design and accident investigation at railway level crossings.

Preventing infections following caesarean section

Surgical site infections following caesarean section are a serious and costly adverse event for Australian hospitals. In the United Kingdom, 9% of women are diagnosed with a surgical site infection following caesarean section either in hospital or post-discharge (Wloch et al 2012, Ward et al 2008). Additional staff time, pharmaceuticals and health supplies, and increased length of stay or readmission to hospital are often required (Henman et al 2012). Part of my PhD investigated the economics of preventing post-caesarean infection. This paper summarises a review of relevant infection prevention strategies. Administering antibiotic prophylaxis 15 to 60 minutes pre-incision, rather than post cordclamping, is probably the most important infection prevention strategy for caesarean section (Smaill and Gyte2010, Liu et al 2013, Dahlke et al 2013). However the timing of antibiotic administration is reportedly inconsistent in Australian hospitals. Clinicians may be taking advice from the influential, but out-dated RANZCOG and United States Centers for Disease Control and Prevention guidelines (Royal Australian and New Zealand College of Obstetricians and Gynaecologists 2011, Mangram et al 1999). A number of other important international clinical guidelines, including Australia's NHMRC guidelines, recommend universal prophylactic antibiotics pre-incision for caesarean section (National Health and Medical Research Council 2010, National Collaborating Centre for Women's and Children's Health 2008, Anderson et al 2008, National Collaborating Centre for Women's and Children's Health 2011, Bratzler et al 2013, American College of Obstetricians and Gynecologists 2011a, Antibiotic Expert Group 2010). We need to ensure women receive preincision antibiotic prophylaxis, particularly as nurses and midwives play a significant role in managing an infection that may result from sub-optimal practice. It is acknowledged more explicitly now that nurses and midwives can influence prescribing and administration of antibiotics through informal approaches (Edwards et al 2011). Methods such as surgical safety checklists are a more formal way for nurses and midwives to ensure that antibiotics are administered pre-incision (American College of Obstetricians and Gynecologists 2011 b). Nurses and midwives can also be directly responsible for other infection prevention strategies such as instructing women to not remove pubic hair in the month before the expected date of delivery and wound management education (Ng et al 2013). Potentially more costly but effective strategies include using a Chlorhexidine-gluconate (CHG) sponge preoperatively (in addition to the usual operating room skin preparation) and vaginal cleansing with a povidone-iodine solution (Riley et al 2012, Rauk 2010, Haas, Morgan, and Contreras 2013).

Assessment of the effects of maternal exposure to heatwave on birth outcomes in Brisbane, Australia

Even though heatwave events have become more frequent and intense in most regions around the world, little is known about the impact of heatwave on birth outcomes. This thesis uses a population-based study design to investigate the relationship between maternal heatwave exposure and adverse birth outcomes in Brisbane, Australia. This study found that heatwave exposure at any stage of pregnancy can be harmful to fetal growth, and further increase the risk of adverse birth outcomes. Both short- and long-term effects of heatwave on adverse birth outcomes were found. The findings in this thesis may have significant public health implications.

Demand Response for Residential Appliances in a Smart Electricity Distribution Network: Utility and Customer Perspectives

This thesis introduces advanced Demand Response algorithms for residential appliances to provide benefits for both utility and customers. The algorithms are engaged in scheduling appliances appropriately in a critical peak day to alleviate network peak, adverse voltage conditions and wholesale price spikes also reducing the cost of residential energy consumption. Initially, a demand response technique via customer reward is proposed, where the utility controls appliances to achieve network improvement. Then, an improved real-time pricing scheme is introduced and customers are supported by energy management schedulers to actively participate in it. Finally, the demand response algorithm is improved to provide frequency regulation services.

Modelling the water, energy and economic nexus

The mining industry faces three long term strategic risks in relation to its water and energy use: 1) securing enough water and energy to meet increased production; 2) reducing water use, energy consumption and emissions due to social, environmental and economic pressures; and 3) understanding the links between water and energy, so that an improvement in one area does not create an adverse effect in another. This project helps the industry analyse these risks by creating a hierarchical systems model (HSM) that represents the water and energy interactions on a sub-site, site and regional scales; which is coupled with a flexible risk framework. The HSM consists of: components that represent sources of water and energy; activities that use water and energy and off-site destinations of water and produced emissions. It can also represent more complex components on a site, with inbuilt examples including tailings dams and water treatment plants. The HSM also allows multiple sites and other infrastructure to be connected together to explore regional water and energy interactions. By representing water and energy as a single interconnected system the HSM can explore tradeoffs and synergies. For example, on a synthetic case study, which represents a typical site, simulations suggested that while a synergy in terms of water use and energy use could be made when chemical additives were used to enhance dust suppression, there were trade-offs when either thickened tailings or dry processing were used. On a regional scale, the HSM was used to simulate various scenarios, including: mines only withdrawing water when needed; achieving economics-of-scale through use of a single centralised treatment plant rather than smaller decentralised treatment plants; and capturing of fugitive emissions for energy generation. The HSM also includes an integrated risk framework for interpreting model output, so that onsite and off-site impacts of various water and energy management strategies can be compared in a managerial context. The case studies in this report explored company, social and environmental risks for scenarios of regional water scarcity, unregulated saline discharge, and the use of plantation forestry to offset carbon emissions. The HSM was able to represent the non-linear causal relationship at the regional scale, such as the forestry scheme offsetting a small percentage of carbon emissions but causing severe regional water shortages. The HSM software developed in this project will be released as an open source tool to allow industry personnel to easily and inexpensively quantify and explore the links between water use, energy use, and carbon emissions. The tool can be easily adapted to represent specific sites or regions. Case studies conducted in this project highlighted the potential complexity of these links between water, energy, and carbon emissions, as well as the significance of the cumulative effects of these links over time. A deeper understanding of these links is vital for the mining industry in order to progress to more sustainable operations, and the HSM provides an accessible, robust framework for investigating these links.

Genotoxicity of inorganic mercury salts based on disturbed microtubule function

This study investigated the hypothesis that the chromosomal genotoxicity of inorganic mercury results from interaction(s) with cytoskeletal proteins. Effects of Hg2+ salts on functional activities of tubulin and kinesin were investigated by determining tubulin assembly and kinesin-driven motility in cell-free systems. Hg2+ inhibits microtubule assembly at concentrations above 1 μM, and inhibition is complete at about 10 μM. In this range, the tubulin assembly is fully (up to 6 μM) or partially (∼6-10 μM) reversible. The inhibition of tubulin assembly by mercury is independent of the anion, chloride or nitrate. The no-observed-effect- concentration for inhibition of microtubule assembly in vitro was 1 μM Hg2+, the IC50 5.8 μM. Mercury(II) salts at the IC 50 concentrations partly inhibiting tubulin assembly did not cause the formation of aberrant microtubule structures. Effects of mercury salts on the functionality of the microtubule motility apparatus were studied with the motor protein kinesin. By using a "gliding assay" mimicking intracellular movement and transport processes in vitro, HgCl2 affected the gliding velocity of paclitaxel-stabilised microtubules in a clear dose-dependent manner. An apparent effect is detected at a concentration of 0.1 μM and a complete inhibition is reached at 1 μM. Cytotoxicity of mercury chloride was studied in V79 cells using neutral red uptake, showing an influence above 17 μM HgCl2. Between 15 and 20 μM HgCl2 there was a steep increase in cell toxicity. Both mercury chloride and mercury nitrate induced micronuclei concentration-dependently, starting at concentrations above 0.01 μM. CREST analyses on micronuclei formation in V79 cells demonstrated both clastogenic (CREST-negative) and aneugenic effects of Hg2+, with some preponderance of aneugenicity. A morphological effect of high Hg2+ concentrations (100 μM HgCl2) on the microtubule cytoskeleton was verified in V79 cells by immuno-fluorescence staining. The overall data are consistent with the concept that the chromosomal genotoxicity could be due to interaction of Hg2+ with the motor protein kinesin mediating cellular transport processes. Interactions of Hg 2+ with the tubulin shown by in vitro investigations could also partly influence intracellular microtubule functions leading, together with the effects on the kinesin, to an impaired chromosome distribution as shown by the micronucleus test.

A systematic review of the effectiveness of warming interventions for women undergoing cesarean section

Women undergoing cesarean section are vulnerable to adverse effects associated with inadvertent perioperative hypothermia, but there has been a lack of synthesized evidence for temperature management in this population. This systematic review aimed to synthesize the best available evidence in relation to preventing hypothermia in mothers undergoing cesarean section surgery.

Privacy concerns and purchase of travel product online

The travel and tourism industry has come to rely heavily on information and communication technologies to facilitate relations with consumers. Compiling consumer data profiles has become easier and it is widely thought that consumers place great importance on how that data is handled by firms. Lack of trust may cause consumers to have privacy concerns and may, in turn, have an adverse impact on consumers’ willingness to purchase online. Three specific aspects of privacy that have received attention from researchers are unauthorized use of secondary data, invasion of privacy, and errors. A survey study was undertaken to examine the effects of these factors on both prior purchase of travel products via the Internet and future purchase probability. Surprisingly, no significant relationships were found to indicate that such privacy concerns affect online purchase behavior within the travel industry. Implications for managers are discussed.

The capture and retention evaluation of a stormwater gross pollutant trap design

Gross pollutant traps (GPT) are designed to capture and retain visible street waste, such as anthropogenic litter and organic matter. Blocked screens, low/high downstream tidal waters and flows operating above/below the intended design limits can hamper the operations of a stormwater GPT. Under these adverse operational conditions, a recently developed GPT was evaluated. Capture and retention experiments were conducted on a 50% scale model with partially and fully blocked screens, placed inside a hydraulic flume. Flows were established through the model via an upstream channel-inlet configuration. Floatable, partially buoyant, neutrally buoyant and sinkable spheres were released into the GPT and monitored at the outlet. These experiments were repeated with a pipe-inlet configured GPT. The key findings from the experiments were of practical significance to the design, operation and maintenance of GPTs. These involved an optimum range of screen blockages and a potentially improved inlet design for efficient gross pollutant capture/retention operations. For example, the outlet data showed that the capture and retention efficiency deteriorated rapidly when the screens were fully blocked. The low pressure drop across the retaining screens and the reduced inlet flow velocities were either insufficient to mobilise the gross pollutants, or the GPT became congested.

Incorporating human-factors in car-following models : a review of recent developments and research needs

Over the past decades there has been a considerable development in the modeling of car-following (CF) behavior as a result of research undertaken by both traffic engineers and traffic psychologists. While traffic engineers seek to understand the behavior of a traffic stream, traffic psychologists seek to describe the human abilities and errors involved in the driving process. This paper provides a comprehensive review of these two research streams. It is necessary to consider human-factors in {CF} modeling for a more realistic representation of {CF} behavior in complex driving situations (for example, in traffic breakdowns, crash-prone situations, and adverse weather conditions) to improve traffic safety and to better understand widely-reported puzzling traffic flow phenomena, such as capacity drop, stop-and-go oscillations, and traffic hysteresis. While there are some excellent reviews of {CF} models available in the literature, none of these specifically focuses on the human factors in these models. This paper addresses this gap by reviewing the available literature with a specific focus on the latest advances in car-following models from both the engineering and human behavior points of view. In so doing, it analyses the benefits and limitations of various models and highlights future research needs in the area.

Impacts of introduced aquaculture species on markets for native marine aquaculture products : the case of edible oysters in Australia

Economic competition between introduced and native aquaculture species is of interest for industry stakeholders since increased production can affect price formation if both aquaculture species are part of the same market or even substitutes. In this study, we focus on the Australian edible oyster industry, which is dominated by two major species—the native Sydney rock oyster (grown mainly in Queensland and New South Wales) and the non-native Pacific oyster (grown mainly in South Australia and Tasmania). We examine the integration of the Australian oyster market to determine if there exists a single or several markets. Short- and long-run own, cross-price and income flexibilities of demand are estimated for both species using an inverse demand system of equations. The results suggest that the markets for the two species are integrated. We found evidence that the development of the Pacific oyster industry has had an adverse impact on Sydney rock oyster prices. However, our results show that both species are not perfect substitutes. Demand for Sydney rock oysters is relatively inelastic in the long run, yet no long-run relationships can be identified for Pacific oysters, reflecting the developing nature of this sector.

Regulating supply chains to improve health and safety

The fragmentation of previously integrated systems of production and service delivery has been an important feature of organisational restructuring over the last three decades. This article highlights the adverse implications of this development for the health and safety of workers, examines the extent to which current British health and safety law provides an adequate framework for addressing these outcomes and explores whether its capacity to do so could be enhanced through the introduction of new statutory provisions on the regulation of supply chains. It concludes that, in terms of both structure and operation, the present framework of law is problematic. It further argues that recent international initiatives show that it is feasible to develop such statutory provisions and that existing evidence suggests that provisions of this type could usefully be introduced in respect of a number of areas of activity where the implications of the externalisation of production and service delivery seem particularly problematic.

Australian health and safety inspectors’ perceptions and actions in relation to changed work arrangements

Extensive international research points to an association between changed work arrangements, especially those commonly labelled as contingent work, with adverse occupational health and safety (OHS) outcomes. Research also indicates these work arrangements have weakened or bypassed existing OHS and workers’ compensation regulatory regimes. However, there has been little if any research into how OHS inspectors perceive these issues and how they address them during workplace visits or investigations. Between 2003 and 2007 research was undertaken that entailed detailed documentary and statistical analysis, extended interviews with 170 regulatory managers and inspectors, and observational data collected while accompanying inspectors on 118 ‘typical’ workplace visits. Key findings are that inspectors responsible for a range of industries see altered work arrangements as a serious challenge, especially labour hire (agency work) and subcontracting. Though the law imposes clear obligations, inspectors identified misunderstanding/blameshifting and poor compliance amongst parties to these arrangements. The complexity of these work arrangements also posed logistical challenges to inspectorates.