Setting hospital infection control policy : a decision-making framework incorporating health economics and healthcare epidemiology

Background: Reducing rates of healthcare acquired infection has been identified by the Australian Commission on Safety and Quality in Health Care as a national priority. One of the goals is the prevention of central venous catheter-related bloodstream infection (CR-BSI). At least 3,500 cases of CR-BSI occur annually in Australian hospitals, resulting in unnecessary deaths and costs to the healthcare system between $25.7 and $95.3 million. Two approaches to preventing these infections have been proposed: use of antimicrobial catheters (A-CVCs); or a catheter care and management ‘bundle’. Given finite healthcare budgets, decisions about the optimal infection control policy require consideration of the effectiveness and value for money of each approach. Objectives: The aim of this research is to use a rational economic framework to inform efficient infection control policy relating to the prevention of CR-BSI in the intensive care unit. It addresses three questions relating to decision-making in this area: 1. Is additional investment in activities aimed at preventing CR-BSI an efficient use of healthcare resources? 2. What is the optimal infection control strategy from amongst the two major approaches that have been proposed to prevent CR-BSI? 3. What uncertainty is there in this decision and can a research agenda to improve decision-making in this area be identified? Methods: A decision analytic model-based economic evaluation was undertaken to identify an efficient approach to preventing CR-BSI in Queensland Health intensive care units. A Markov model was developed in conjunction with a panel of clinical experts which described the epidemiology and prognosis of CR-BSI. The model was parameterised using data systematically identified from the published literature and extracted from routine databases. The quality of data used in the model and its validity to clinical experts and sensitivity to modelling assumptions was assessed. Two separate economic evaluations were conducted. The first evaluation compared all commercially available A-CVCs alongside uncoated catheters to identify which was cost-effective for routine use. The uncertainty in this decision was estimated along with the value of collecting further information to inform the decision. The second evaluation compared the use of A-CVCs to a catheter care bundle. We were unable to estimate the cost of the bundle because it is unclear what the full resource requirements are for its implementation, and what the value of these would be in an Australian context. As such we undertook a threshold analysis to identify the cost and effectiveness thresholds at which a hypothetical bundle would dominate the use of A-CVCs under various clinical scenarios. Results: In the first evaluation of A-CVCs, the findings from the baseline analysis, in which uncertainty is not considered, show that the use of any of the four A-CVCs will result in health gains accompanied by cost-savings. The MR catheters dominate the baseline analysis generating 1.64 QALYs and cost-savings of $130,289 per 1.000 catheters. With uncertainty, and based on current information, the MR catheters remain the optimal decision and return the highest average net monetary benefits ($948 per catheter) relative to all other catheter types. This conclusion was robust to all scenarios tested, however, the probability of error in this conclusion is high, 62% in the baseline scenario. Using a value of $40,000 per QALY, the expected value of perfect information associated with this decision is $7.3 million. An analysis of the expected value of perfect information for individual parameters suggests that it may be worthwhile for future research to focus on providing better estimates of the mortality attributable to CR-BSI and the effectiveness of both SPC and CH/SSD (int/ext) catheters. In the second evaluation of the catheter care bundle relative to A-CVCs, the results which do not consider uncertainty indicate that a bundle must achieve a relative risk of CR-BSI of at least 0.45 to be cost-effective relative to MR catheters. If the bundle can reduce rates of infection from 2.5% to effectively zero, it is cost-effective relative to MR catheters if national implementation costs are less than $2.6 million ($56,610 per ICU). If the bundle can achieve a relative risk of 0.34 (comparable to that reported in the literature) it is cost-effective, relative to MR catheters, if costs over an 18 month period are below $613,795 nationally ($13,343 per ICU). Once uncertainty in the decision is considered, the cost threshold for the bundle increases to $2.2 million. Therefore, if each of the 46 Level III ICUs could implement an 18 month catheter care bundle for less than $47,826 each, this approach would be cost effective relative to A-CVCs. However, the uncertainty is substantial and the probability of error in concluding that the bundle is the cost-effective approach at a cost of $2.2 million is 89%. Conclusions: This work highlights that infection control to prevent CR-BSI is an efficient use of healthcare resources in the Australian context. If there is no further investment in infection control, an opportunity cost is incurred, which is the potential for a more efficient healthcare system. Minocycline/rifampicin catheters are the optimal choice of antimicrobial catheter for routine use in Australian Level III ICUs, however, if a catheter care bundle implemented in Australia was as effective as those used in the large studies in the United States it would be preferred over the catheters if it was able to be implemented for less than $47,826 per Level III ICU. Uncertainty is very high in this decision and arises from multiple sources. There are likely greater costs to this uncertainty for A-CVCs, which may carry hidden costs, than there are for a catheter care bundle, which is more likely to provide indirect benefits to clinical practice and patient safety. Research into the mortality attributable to CR-BSI, the effectiveness of SPC and CH/SSD (int/ext) catheters and the cost and effectiveness of a catheter care bundle in Australia should be prioritised to reduce uncertainty in this decision. This thesis provides the economic evidence to inform one area of infection control, but there are many other infection control decisions for which information about the cost-effectiveness of competing interventions does not exist. This work highlights some of the challenges and benefits to generating and using economic evidence for infection control decision-making and provides support for commissioning more research into the cost-effectiveness of infection control.

Communication of business process models via virtual environment simulations

Games and related virtual environments have been a much-hyped area of the entertainment industry. The classic quote is that games are now approaching the size of Hollywood box office sales [1]. Books are now appearing that talk up the influence of games on business [2], and it is one of the key drivers of present hardware development. Some of this 3D technology is now embedded right down at the operating system level via the Windows Presentation Foundations – hit Windows/Tab on your Vista box to find out... In addition to this continued growth in the area of games, there are a number of factors that impact its development in the business community. Firstly, the average age of gamers is approaching the mid thirties. Therefore, a number of people who are in management positions in large enterprises are experienced in using 3D entertainment environments. Secondly, due to the pressure of demand for more computational power in both CPU and Graphical Processing Units (GPUs), your average desktop, any decent laptop, can run a game or virtual environment. In fact, the demonstrations at the end of this paper were developed at the Queensland University of Technology (QUT) on a standard Software Operating Environment, with an Intel Dual Core CPU and basic Intel graphics option. What this means is that the potential exists for the easy uptake of such technology due to 1. a broad range of workers being regularly exposed to 3D virtual environment software via games; 2. present desktop computing power now strong enough to potentially roll out a virtual environment solution across an entire enterprise. We believe such visual simulation environments can have a great impact in the area of business process modeling. Accordingly, in this article we will outline the communication capabilities of such environments, giving fantastic possibilities for business process modeling applications, where enterprises need to create, manage, and improve their business processes, and then communicate their processes to stakeholders, both process and non-process cognizant. The article then concludes with a demonstration of the work we are doing in this area at QUT.

Settings for mental health care

The quality of the environment is important to client recovery and rehabilitation. • The preferred environment for the care of the mentally ill over time has been the home. • Environmental strategies in the care of the mentally ill became more important in the eighteenth century, when it was noticed that patients were more manageable in a pleasant environment. • Confinement of the mentally ill in large public asylums was largely an innovation of the nineteenth century. • The therapeutic milieu is a consciously organised environment. • Maxwell Jones in the United States and Thomas Main in the United Kingdom pioneered the concept of the hospital and environment as treatment tools. • The goals of the therapeutic milieu are containment, structure, support, involvement, validation, symptom management, and maintaining links with family and the community. • The principles on which the therapeutic milieu is based include: open communication, democratisation, reality confrontation, permissiveness, group cohesion and the multidisciplinary team. • The principle guiding the care of clients in the community is that of the least-restrictive alternative. • The therapeutic community residence is an environment that encourages the development of the client as a person in interaction with others, rather than as someone suffering from a health problem or disability. • The preferred contemporary setting for the provision of mental health care is the community. • The predominant form of service delivery in the community is case management, which has been found to be most effective for people with severe mental illnesses. • The principles of caring in the community are self-determination, normalisation, a focus on client strengths, and the community as a resource

Theoretical investigation of mechanisms of formation and interaction of nanoparticles

In this thesis an investigation into theoretical models for formation and interaction of nanoparticles is presented. The work presented includes a literature review of current models followed by a series of five chapters of original research. This thesis has been submitted in partial fulfilment of the requirements for the degree of doctor of philosophy by publication and therefore each of the five chapters consist of a peer-reviewed journal article. The thesis is then concluded with a discussion of what has been achieved during the PhD candidature, the potential applications for this research and ways in which the research could be extended in the future. In this thesis we explore stochastic models pertaining to the interaction and evolution mechanisms of nanoparticles. In particular, we explore in depth the stochastic evaporation of molecules due to thermal activation and its ultimate effect on nanoparticles sizes and concentrations. Secondly, we analyse the thermal vibrations of nanoparticles suspended in a fluid and subject to standing oscillating drag forces (as would occur in a standing sound wave) and finally on lattice surfaces in the presence of high heat gradients. We have described in this thesis a number of new models for the description of multicompartment networks joined by a multiple, stochastically evaporating, links. The primary motivation for this work is in the description of thermal fragmentation in which multiple molecules holding parts of a carbonaceous nanoparticle may evaporate. Ultimately, these models predict the rate at which the network or aggregate fragments into smaller networks/aggregates and with what aggregate size distribution. The models are highly analytic and describe the fragmentation of a link holding multiple bonds using Markov processes that best describe different physical situations and these processes have been analysed using a number of mathematical methods. The fragmentation of the network/aggregate is then predicted using combinatorial arguments. Whilst there is some scepticism in the scientific community pertaining to the proposed mechanism of thermal fragmentation,we have presented compelling evidence in this thesis supporting the currently proposed mechanism and shown that our models can accurately match experimental results. This was achieved using a realistic simulation of the fragmentation of the fractal carbonaceous aggregate structure using our models. Furthermore, in this thesis a method of manipulation using acoustic standing waves is investigated. In our investigation we analysed the effect of frequency and particle size on the ability for the particle to be manipulated by means of a standing acoustic wave. In our results, we report the existence of a critical frequency for a particular particle size. This frequency is inversely proportional to the Stokes time of the particle in the fluid. We also find that for large frequencies the subtle Brownian motion of even larger particles plays a significant role in the efficacy of the manipulation. This is due to the decreasing size of the boundary layer between acoustic nodes. Our model utilises a multiple time scale approach to calculating the long term effects of the standing acoustic field on the particles that are interacting with the sound. These effects are then combined with the effects of Brownian motion in order to obtain a complete mathematical description of the particle dynamics in such acoustic fields. Finally, in this thesis, we develop a numerical routine for the description of "thermal tweezers". Currently, the technique of thermal tweezers is predominantly theoretical however there has been a handful of successful experiments which demonstrate the effect it practise. Thermal tweezers is the name given to the way in which particles can be easily manipulated on a lattice surface by careful selection of a heat distribution over the surface. Typically, the theoretical simulations of the effect can be rather time consuming with supercomputer facilities processing data over days or even weeks. Our alternative numerical method for the simulation of particle distributions pertaining to the thermal tweezers effect use the Fokker-Planck equation to derive a quick numerical method for the calculation of the effective diffusion constant as a result of the lattice and the temperature. We then use this diffusion constant and solve the diffusion equation numerically using the finite volume method. This saves the algorithm from calculating many individual particle trajectories since it is describes the flow of the probability distribution of particles in a continuous manner. The alternative method that is outlined in this thesis can produce a larger quantity of accurate results on a household PC in a matter of hours which is much better than was previously achieveable.

Virtual Environment Visualisation of Executable Business Process Models

Business Process Modelling is a fast growing field in business and information technology, which uses visual grammars to model and execute the processes within an organisation. However, many analysts present such models in a 2D static and iconic manner that is difficult to understand by many stakeholders. Difficulties in understanding such grammars can impede the improvement of processes within an enterprise due to communication problems. In this chapter we present a novel framework for intuitively visualising animated business process models in interactive Virtual Environments. We also show that virtual environment visualisations can be performed with present 2D business process modelling technology, thus providing a low barrier to entry for business process practitioners. Two case studies are presented from film production and healthcare domains that illustrate the ease with which these visualisations can be created. This approach can be generalised to other executable workflow systems, for any application domain being modelled.

Investigating users’ intuitive interaction with complex artefacts

This paper examines the role of intuition in the way that people operate unfamiliar devices. Intuition is a type of cognitive processing that is often non-conscious and utilises stored experiential knowledge. Intuitive interaction involves the use of knowledge gained from other products and/or experiences. Two initial experimental studies revealed that prior exposure to products employing similar features helped participants to complete set tasks more quickly and intuitively, and that familiar features were intuitively used more often than unfamiliar ones. A third experiment confirmed that performance is affected by a person's level of familiarity with similar technologies, and also revealed that appearance (shape, size and labelling of features) seems to be the variable that most affects time spent on a task and intuitive uses during that time. Age also seems to have an effect. These results and their implications are discussed.

In Interaction

The field was the design of cross-cultural media art exhibition outcomes for the Japanese marketplace. The context was improved understandings of spatial, temporal and contextual exhibition design procedures as they ultimately impact upon the augmentation of cross-cultural understanding. The research investigated cross-cultural new media exhibition practices suited to the specific sensitivies of Japanese exhibition practices. The methodology was principally practice-led. The research drew upon seven years of prior exhibition design practices in order to generate new Japanese exhibition design methodologies. It also empowered Zaim Artpsace’s Japanese curators to later present a range of substantial new media shows. The project also succeeded in developing new cross-cultural alliances that led to significant IDA projects in Beijing, Australia and Europe in the years 2008-10. Through invitations from external curators the new versions of the exhibition work subsequently travelled to 4 other major venues including the prestigious Songzhang Art Museum, Beijing in 07/08, the Block, QUT, Brisbane and the Tokyo International Film festival. Inspiration Art Press printed a major catalogue for the event extensively featuring this exhibition. This project also led to the Sudamalis (2007) paper, ‘Building Capacity: Literacy And Creative Workforce Development Through International Digital Arts Projects’ (IDAprojects) Exhibition Programs And Partnerships’.

Are organ donation communication decisions reasoned or reactive? A test of the utility of an augmented Theory of Planned Behaviour with the Prototype/Willingness Model

Objectives: To explore whether people's organ donation consent decisions occur via a reasoned and/or social reaction pathway. --------- Design: We examined prospectively students' and community members' decisions to register consent on a donor register and discuss organ donation wishes with family. --------- Method: Participants completed items assessing theory of planned behaviour (TPB; attitude, subjective norm, perceived behavioural control (PBC)), prototype/willingness model (PWM; donor prototype favourability/similarity, past behaviour), and proposed additional influences (moral norm, self-identity, recipient prototypes) for registering (N=339) and discussing (N=315) intentions/willingness. Participants self-reported their registering (N=177) and discussing (N=166) behaviour 1 month later. The utility of the (1) TPB, (2) PWM, (3) augmented TPB with PWM, and (4) augmented TPB with PWM and extensions was tested using structural equation modelling for registering and discussing intentions/willingness, and logistic regression for behaviour. --------- Results: While the TPB proved a more parsimonious model, fit indices suggested that the other proposed models offered viable options, explaining greater variance in communication intentions/willingness. The TPB, augmented TPB with PWM, and extended augmented TPB with PWM best explained registering and discussing decisions. The proposed and revised PWM also proved an adequate fit for discussing decisions. Respondents with stronger intentions (and PBC for registering) had a higher likelihood of registering and discussing. --------- Conclusions: People's decisions to communicate donation wishes may be better explained via a reasoned pathway (especially for registering); however, discussing involves more reactive elements. The role of moral norm, self-identity, and prototypes as influences predicting communication decisions were highlighted also.

Interaction and mediation in preadmission clinics : implications for the design of a telehealth stethoscope

A telehealth stethoscope would make it possible for doctors to perform physical examinations on patients at great distances. In order to develop a useful and usable telehealth stethoscope we have conducted fieldwork observations of existing anaesthetic preadmission clinics to understand how stethoscopes are currently used. Both face-to-face consultations and videoconference consultations have been studied. Our results indicate that the stethoscope plays a minor role in the consultation and that consultations are mediated by the administrative work that is the reason for the consultation. We suggest that a stethoscope plays an infrastructural role in the consultation. The implications of considering stethoscopes as infrastructure are explored and considered in the context of a future telehealth stethoscope.

Virtual fencing applications : Implementing and testing an automated cattle control system

Managing livestock movement in extensive systems has environmental and production benefits. Currently permanent wire fencing is used to control cattle; this is both expensive and inflexible. Cattle are known to respond to auditory and visual cues and we investigated whether these can be used to manipulate their behaviour. Twenty-five Belmont Red steers with a mean live weight of 270kg were each randomly assigned to one of five treatments. Treatments consisted of a combination of cues (audio, tactile and visual stimuli) and consequence (electrical stimulation). The treatments were electrical stimulation alone, audio plus electrical stimulation, vibration plus electrical stimulation, light plus electrical stimulation and electrified electric fence (6kV) plus electrical stimulation. Cue stimuli were administered for 3s followed immediately by electrical stimulation (consequence) of 1kV for 1s. The experiment tested the operational efficacy of an on-animal control or virtual fencing system. A collar-halter device was designed to carry the electronics, batteries and equipment providing the stimuli, including audio, vibration, light and electrical of a prototype virtual fencing device. Cattle were allowed to travel along a 40m alley to a group of peers and feed while their rate of travel and response to the stimuli were recorded. The prototype virtual fencing system was successful in modifying the behaviour of the cattle. The rate of travel of cattle along the alley demonstrated the large variability in behavioural response associated with tactile, visual and audible cues. The experiment demonstrated virtual fencing has potential for controlling cattle in extensive grazing systems. However, larger numbers of cattle need to be tested to derive a better understanding of the behavioural variance. Further controlled experimental work is also necessary to quantify the interaction between cues, consequences and cattle learning.

PIPP #1 - Pedestrian Interaction Patch Project

The Pedestrian Interaction Patch Project (PIPP) seeks to exert influence over and encourage abnormal pedestrian behavior. By placing an unadvertised (and non recording) interactive video manipulation system and projection source in a high traffic public area, the PIPP allows pedestrians to privately (and publically) re-engage with a previously inactive physical environment, like a commonly used walkway or corridor. This system, the results of which are projected in real time on the architectural surface, inadvertently provides pedestrians with questions around preconceived notions of self and space. In an attempt to re-activate our relationship with the physical surrounds we occupy each day the PIPP creates a new set of memories to be recalled as we re-enter known environments once PIPP has moved on and as such re-enlivens our relationship with the everyday architecture we stroll past everyday. The PIPP environment is controlled using the software program Isadora, devised by Mark Coniglio at Troika Ranch, and contains a series of video manipulation patches that are designed to not only grab the pedestrians attention but to also encourage a sense of play and interaction between the architecture, the digital environment, the initially unsuspecting participant(s) and the pedestrian audience. The PIPP was included as part of the planned walking tour for the “Playing in Urban Spaces” seminar day, and was an installation that ran for the length of the symposium in a reclaimed pedestrian space that was encountered by both the participants and general public during the course of the day long event. Ideally once discovered PIPP encouraged pedestrians to return through the course of the seminar day to see if the environmental patches had changed or altered, and changed their standard route to include the PIPP installation or to avoid it, either way, encouraging an active response to the pathways normally traveled or newly discovered each day.

Assessment of oral proficiency in EAP programs : a case for pair interaction

Reliability and validity in the testing of spoken language are essential in order to assess learners' English language proficiency as evidence of their readiness to begin courses in tertiary institutions. Research has indicated that the task chosen to elicit language samples can have a marked effect on both the nature of the interaction, including the power differential, and assessment, raising the issue of ethics. This exploratory studey, with a group of 32 students from the Peoples's Republic of China preparing for tertiary study in Singapore, compares test-takers' reactions to the use of an oral proficiency interview and a pair interaction.

Interaction between disinhibition and restraint: Implications for body weight and eating disturbance

An increase in obesity is usually accompanied by an increase in eating disturbances. Susceptibility to these states may arise from different combinations of underlying traits: Three Factor Eating Questionnaire (TFEQ) Restraint and Disinhibition. Two studies were conducted to examine the interaction between these traits; one on-line study (n=351) and one laboratory-based study (n=120). Participants completed a battery of questionnaires and provided self-report measures of body weight and physical activity. A combination of high Disinhibition and high Restraint was associated with a problematic eating behaviour profile (EAT-26), and a higher rate of smoking and alcohol consumption. A combination of high Disinhibition and low Restraint was associated with a higher susceptibility to weight gain and a higher sedentary behaviour. These data show that different combinations of Disinhibition and Restraint are associated with distinct weight and behaviour outcomes.