Stress on the ward: evidence of safety tipping points in hospitals

Do hospitals experience safety tipping points as utilization increases, and if so, what are the implications for hospital operations management? We argue that safety tipping points occur when managerial escalation policies are exhausted and workload variability buffers are depleted. Front-line clinical staff is forced to ration resources and, at the same time, becomes more error prone as a result of elevated stress hormone levels. We confirm the existence of safety tipping points for in-hospital mortality using the discharge records of 82,280 patients across six high-mortality-risk conditions from 256 clinical departments of 83 German hospitals. Focusing on survival during the first seven days following admission, we estimate a mortality tipping point at an occupancy level of 92.5%. Among the 17% of patients in our sample who experienced occupancy above the tipping point during the first seven days of their hospital stay, high occupancy accounted for one in seven deaths. The existence of a safety tipping point has important implications for hospital management. First, flexible capacity expansion is more cost-effective for safety improvement than rigid capacity, because it will only be used when occupancy reaches the tipping point. In the context of our sample, flexible staffing saves more than 40% of the cost of a fully staffed capacity expansion, while achieving the same reduction in mortality. Second, reducing the variability of demand by pooling capacity in hospital clusters can greatly increase safety in a hospital system, because it reduces the likelihood that a patient will experience occupancy levels beyond the tipping point. Pooling the capacity of nearby hospitals in our sample reduces the number of deaths due to high occupancy by 34%.

Stress-strain response of hydrate-bearing sands: Numerical study using discrete element method simulations

Gas hydrate is a crystalline solid found within marine and subpermafrost sediments. While the presence of hydrates can have a profound effect on sediment properties, the stress-strain behavior of hydrate-bearing sediments is poorly understood due to inherent limitations in laboratory testing. In this study, we use numerical simulations to improve our understanding of the mechanical behavior of hydrate-bearing sands. The hydrate mass is simulated as either small randomly distributed bonded grains or as "ripened hydrate" forming patchy saturation, whereby sediment clusters with 100% pore-filled hydrate saturation are distributed within a hydrate-free sediment. Simulation results reveal that reduced sand porosity and higher hydrate saturation cause an increase in stiffness, strength, and dilative tendency, and the critical state line shifts toward higher void ratio and higher shear strength. In particular, the critical state friction angle increases in sands with patchy saturation, while the apparent cohesion is affected the most when the hydrate mass is distributed in pores. Sediments with patchy hydrate distribution exhibit a slightly lower strength than sediments with randomly distributed hydrate. Finally, hydrate dissociation under drained conditions leads to volume contraction and/or stress relaxation, and pronounced shear strains can develop if the hydrate-bearing sand is subjected to deviatoric loading during dissociation.

An examination of strain space versus stress space for the formulation of elastoplastic constitutive models

Several elastoplastic soil models have been proposed over the years that are formulated in strain space rather than stress space due to certain analytical and computational advantages. One such model, BRICK (Simpson 1992), has been continuously utilized and developed for industrial applications within Arup Geotechnics for more than two decades. This paper aims to describe the advantages and difficulties associated with strain space modeling. In addition, it will show how recent advances in modeling the effects of stress history, stiffness anisotropy, strength anisotropy and time-dependence in conventional stress space models can be transferred to the BRICK model. © 2010 Taylor & Francis Group, London.

The influence of matrix integrity on stress-fiber remodeling in 3D.

Matrix anisotropy is important for long term in vivo functionality. However, it is not fully understood how to guide matrix anisotropy in vitro. Experiments suggest actin-mediated cell traction contributes. Although F-actin in 2D displays a stretch-avoidance response, 3D data are lacking. We questioned how cyclic stretch influences F-actin and collagen orientation in 3D. Small-scale cell-populated fibrous tissues were statically constrained and/or cyclically stretched with or without biochemical agents. A rectangular array of silicone posts attached to flexible membranes constrained a mixture of cells, collagen I and matrigel. F-actin orientation was quantified using fiber-tracking software, fitted using a bi-model distribution function. F-actin was biaxially distributed with static constraint. Surprisingly, uniaxial cyclic stretch, only induced a strong stretch-avoidance response (alignment perpendicular to stretching) at tissue surfaces and not in the core. Surface alignment was absent when a ROCK-inhibitor was added, but also when tissues were only statically constrained. Stretch-avoidance was also observed in the tissue core upon MMP1-induced matrix perturbation. Further, a strong stretch-avoidance response was obtained for F-actin and collagen, for immediate cyclic stretching, i.e. stretching before polymerization of the collagen. Results suggest that F-actin stress-fibers avoid cyclic stretch in 3D, unless collagen contact guidance dictates otherwise.

The influence of matrix integrity on stress-fiber remodeling in 3D

Matrix anisotropy is important for long term in vivo functionality. However, it is not fully understood how to guide matrix anisotropy in vitro. Experiments suggest actin-mediated cell traction contributes. Although F-actin in 2D displays a stretch-avoidance response, 3D data are lacking. We questioned how cyclic stretch influences F-actin and collagen orientation in 3D. Small-scale cell-populated fibrous tissues were statically constrained and/or cyclically stretched with or without biochemical agents. A rectangular array of silicone posts attached to flexible membranes constrained a mixture of cells, collagen I and matrigel. F-actin orientation was quantified using fiber-tracking software, fitted using a bi-model distribution function. F-actin was biaxially distributed with static constraint. Surprisingly, uniaxial cyclic stretch, only induced a strong stretch-avoidance response (alignment perpendicular to stretching) at tissue surfaces and not in the core. Surface alignment was absent when a ROCK-inhibitor was added, but also when tissues were only statically constrained. Stretch-avoidance was also observed in the tissue core upon MMP1-induced matrix perturbation. Further, a strong stretch-avoidance response was obtained for F-actin and collagen, for immediate cyclic stretching, i.e. stretching before polymerization of the collagen. Results suggest that F-actin stress-fibers avoid cyclic stretch in 3D, unless collagen contact guidance dictates otherwise. © 2012 Elsevier Ltd.

Local stress relaxation and shear banding in a dry foam under shear.

We have developed a realistic simulation of 2D dry foams under quasistatic shear. After a short transient, a shear-banding instability is observed. These results are compared with measurements obtained on real 2D (confined) foams. The numerical model allows us to exhibit the mechanical response of the material to a single plastication event. From the analysis of this elastic propagator, we propose a scenario for the onset and stability of the flow localization process in foams, which should remain valid for most athermal amorphous systems under creep flow.

SOI membrane-based pressure sensor in stress sensitive differential amplifier configuration

This paper introduces a pressure sensing structure configured as a stress sensitive differential amplifier (SSDA), built on a Silicon-on-Insulator (SOI) membrane. Theoretical calculation show the significant increase in sensitivity which is expected from the pressure sensors in SSDA configuration compared to the traditional Wheatstone bridge circuit. Preliminary experimental measurements, performed on individual transistors placed on the membrane, exhibit state-the-art sensitivity values (1.45mV/mbar). © 2012 IEEE.

Mechanical and hydraulic properties of Nankai accretionary prism sediments: Effect of stress path

We have conducted triaxial deformation experiments along different loading paths on prism sediments from the Nankai Trough. Different load paths of isotropic loading, uniaxial strain loading, triaxial compression (at constant confining pressure, Pc), undrained Pc reduction, drained Pc reduction, and triaxial unloading at constant Pc, were used to understand the evolution of mechanical and hydraulic properties under complicated stress states and loading histories in accretionary subduction zones. Five deformation experiments were conducted on three sediment core samples for the Nankai prism, specifically from older accreted sediments at the forearc basin, underthrust slope sediments beneath the megasplay fault, and overthrust Upper Shikoku Basin sediments along the frontal thrust. Yield envelopes for each sample were constructed based on the stress paths of Pc-reduction using the modified Cam-clay model, and in situ stress states of the prism were constrained using the results from the other load paths and accounting for horizontal stress. Results suggest that the sediments in the vicinity of the megasplay fault and frontal thrust are highly overconsolidated, and thus likely to deform brittle rather than ductile. The porosity of sediments decreases as the yield envelope expands, while the reduction in permeability mainly depends on the effective mean stress before yield, and the differential stress after yield. An improved understanding of sediment yield strength and hydromechanical properties along different load paths is necessary to treat accurately the coupling of deformation and fluid flow in accretionary subduction zones. © 2012 American Geophysical Union All Rights Reserved.

Deposition of low stress amorphous zinc tin oxide at ambient temperature using a remote plasma sputtering process suitable for delicate substrates

ZnxSnyOz thin films (<100nm thickness), deposited by remote sputtering from a metal target using a confined argon plasma and oxygen gas jet near the sample, were investigated for their material properties. No visible deformation or curl was observed when deposited on plastic. Materials were confirmed to be amorphous and range between 5 and 10 at.% Sn concentration by x-ray diffraction, x-ray photoemission spectroscopy and energydispersive x-ray spectroscopy. Factors affecting the material composition over time are discussed. Depletion of the Sn as the target ages is suspected. © The Electrochemical Society.