The effectiveness of a nurse practitioner-led pain management team in long-term care: A mixed methods study

BACKGROUND: Considering the high rates of pain as well as its under-management in long-term care (LTC) settings, research is needed to explore innovations in pain management that take into account limited resource realities. It has been suggested that nurse practitioners, working within an inter-professional model, could potentially address the under-management of pain in LTC.

OBJECTIVES: This study evaluated the effectiveness of implementing a nurse practitioner-led, inter-professional pain management team in LTC in improving (a) pain-related resident outcomes; (b) clinical practice behaviours (e.g., documentation of pain assessments, use of non-pharmacological and pharmacological interventions); and, (c) quality of pain medication prescribing practices.

METHODS: A mixed method design was used to evaluate a nurse practitioner-led pain management team, including both a quantitative and qualitative component. Using a controlled before-after study, six LTC homes were allocated to one of three groups: 1) a nurse practitioner-led pain team (full intervention); 2) nurse practitioner but no pain management team (partial intervention); or, 3) no nurse practitioner, no pain management team (control group). In total, 345 LTC residents were recruited to participate in the study; 139 residents for the full intervention group, 108 for the partial intervention group, and 98 residents for the control group. Data was collected in Canada from 2010 to 2012.

RESULTS: Implementing a nurse practitioner-led pain team in LTC significantly reduced residents' pain and improved functional status compared to usual care without access to a nurse practitioner. Positive changes in clinical practice behaviours (e.g., assessing pain, developing care plans related to pain management, documenting effectiveness of pain interventions) occurred over the intervention period for both the nurse practitioner-led pain team and nurse practitioner-only groups; these changes did not occur to the same extent, if at all, in the control group. Qualitative analysis highlighted the perceived benefits of LTC staff about having access to a nurse practitioner and benefits of the pain team, along with barriers to managing pain in LTC.

CONCLUSIONS: The findings from this study showed that implementing a nurse practitioner-led pain team can significantly improve resident pain and functional status as well as clinical practice behaviours of LTC staff. LTC homes should employ a nurse practitioner, ideally located onsite as opposed to an offsite consultative role, to enhance inter-professional collaboration and facilitate more consistent and timely access to pain management.

Crack propagation in non-homogenous materials: Evaluation of mixed-mode SIFs, T-stress and kinking angle using a variant EFG method

A new variant of the Element-Free Galerkin (EFG) method, that combines the diffraction method, to characterize the crack tip solution, and the Heaviside enrichment function for representing discontinuity due to a crack, has been used to model crack propagation through non-homogenous materials. In the case of interface crack propagation, the kink angle is predicted by applying the maximum tangential principal stress (MTPS) criterion in conjunction with consideration of the energy release rate (ERR). The MTPS criterion is applied to the crack tip stress field described by both the stress intensity factor (SIF) and the T-stress, which are extracted using the interaction integral method. The proposed EFG method has been developed and applied for 2D case studies involving a crack in an orthotropic material, crack along an interface and a crack terminating at a bi-material interface, under mechanical or thermal loading; this is done to demonstrate the advantages and efficiency of the proposed methodology. The computed SIFs, T-stress and the predicted interface crack kink angles are compared with existing results in the literature and are found to be in good agreement. An example of crack growth through a particle-reinforced composite materials, which may involve crack meandering around the particle, is reported.

PROPOSAL OF AN EMPIRICAL MODEL FOR SUPPLIERS SELECTION

The problem of selecting suppliers/partners is a crucial and important part in the process of decision making for companies that intend to perform competitively in their area of activity. The selection of supplier/partner is a time and resource-consuming task that involves data collection and a careful analysis of the factors that can positively or negatively influence the choice. Nevertheless it is a critical process that affects significantly the operational performance of each company. In this work, trough the literature review, there were identified five broad suppliers selection criteria: Quality, Financial, Synergies, Cost, and Production System. Within these criteria, it was also included five sub-criteria. Thereafter, a survey was elaborated and companies were contacted in order to answer which factors have more relevance in their decisions to choose the suppliers. Interpreted the results and processed the data, it was adopted a model of linear weighting to reflect the importance of each factor. The model has a hierarchical structure and can be applied with the Analytic Hierarchy Process (AHP) method or Simple Multi-Attribute Rating Technique (SMART). The result of the research undertaken by the authors is a reference model that represents a decision making support for the suppliers/partners selection process.

Evaluation, Selection and Planning the Implementation of a Pavement Management Optimization Model, Phase II Report, 1994

The missions of the research are to assist the Iowa Department of Transortation (Iowa DOT) to: Define pavement management (PM) optimization; Identify the characteristics of PM optimization systems being developed or implemented; Identify specific and achievable objectives for the Iowa DOT pavement management optimization; Evaluate different PM optimization methodologies; Identify a methodology to perform PM optimization that best satisfies the Iowa DOT's objectives; Develop a plan for the implementation of the PM optimization selected. The project is divided into three (3) phases. The first phase has been completed and accomplished the first three missions (identified above). The second phase has been completed and accomplished the next two missions. Phase three will accomplish the last mission.

Quantifying Selection Bias from Birth History Estimates of Child Mortality

Thesis (Master's)--University of Washington, 2016-08

Evolutionary dynamics under various modes of reproduction

Thesis (Ph.D.)--University of Washington, 2016-08

Improved models for estimating temporal changes in carbon sequestration in above-ground biomass of mixed-species environmental plantings

Plantings of mixed native species (termed 'environmental plantings') are increasingly being established for carbon sequestration whilst providing additional environmental benefits such as biodiversity and water quality. In Australia, they are currently one of the most common forms of reforestation. Investment in establishing and maintaining such plantings relies on having a cost-effective modelling approach to providing unbiased estimates of biomass production and carbon sequestration rates. In Australia, the Full Carbon Accounting Model (FullCAM) is used for both national greenhouse gas accounting and project-scale sequestration activities. Prior to undertaking the work presented here, the FullCAM tree growth curve was not calibrated specifically for environmental plantings and generally under-estimated their biomass. Here we collected and analysed above-ground biomass data from 605 mixed-species environmental plantings, and tested the effects of several planting characteristics on growth rates. Plantings were then categorised based on significant differences in growth rates. Growth of plantings differed between temperate and tropical regions. Tropical plantings were relatively uniform in terms of planting methods and their growth was largely related to stand age, consistent with the un-calibrated growth curve. However, in temperate regions where plantings were more variable, key factors influencing growth were planting width, stand density and species-mix (proportion of individuals that were trees). These categories provided the basis for FullCAM calibration. Although the overall model efficiency was only 39-46%, there was nonetheless no significant bias when the model was applied to the various planting categories. Thus, modelled estimates of biomass accumulation will be reliable on average, but estimates at any particular location will be uncertain, with either under- or over-prediction possible. When compared with the un-calibrated yield curves, predictions using the new calibrations show that early growth is likely to be more rapid and total above-ground biomass may be higher for many plantings at maturity. This study has considerably improved understanding of the patterns of growth in different types of environmental plantings, and in modelling biomass accumulation in young (<25. years old) plantings. However, significant challenges remain to understand longer-term stand dynamics, particularly with temporal changes in stand density and species composition. © 2014.

A mixed logit model for predicting exit choice during building evacuations.

Knowledge on human behaviour in emergency is crucial to increase the safety of buildings and transportation systems. Decision making during evacuations implies different choices, of which one of the most important concerns the escape route. The choice of a route may involve local decisions between alternative exits from an enclosed environment. This work investigates the influence of environmental (presence of smoke, emergency lighting and distance of exit) and social factors (interaction with evacuees close to the exits and with those near the decision-maker) on local exit choice. This goal is pursued using an online stated preference survey carried out making use of non-immersive virtual reality. A sample of 1,503 participants is obtained and a Mixed Logit Model is calibrated using these data. The model shows that presence of smoke, emergency lighting, distance of exit, number of evacuees near the exits and the decision-maker, and flow of evacuees through the exits significantly affect local exit choice. Moreover, the model points out that decision making is affected by a high degree of behavioural uncertainty. Our findings support the improvement of evacuation models and the accuracy of their results, which can assist in designing and managing building and transportation systems. The main contribution of this work is to enrich the understanding of how local exit choices are made and how behavioural uncertainty affects these choices.

Optimal Budget-Constrained Sample Allocation for Selection Decisions with Multiple Uncertain Attributes

A decision-maker, when faced with a limited and fixed budget to collect data in support of a multiple attribute selection decision, must decide how many samples to observe from each alternative and attribute. This allocation decision is of particular importance when the information gained leads to uncertain estimates of the attribute values as with sample data collected from observations such as measurements, experimental evaluations, or simulation runs. For example, when the U.S. Department of Homeland Security must decide upon a radiation detection system to acquire, a number of performance attributes are of interest and must be measured in order to characterize each of the considered systems. We identified and evaluated several approaches to incorporate the uncertainty in the attribute value estimates into a normative model for a multiple attribute selection decision. Assuming an additive multiple attribute value model, we demonstrated the idea of propagating the attribute value uncertainty and describing the decision values for each alternative as probability distributions. These distributions were used to select an alternative. With the goal of maximizing the probability of correct selection we developed and evaluated, under several different sets of assumptions, procedures to allocate the fixed experimental budget across the multiple attributes and alternatives. Through a series of simulation studies, we compared the performance of these allocation procedures to the simple, but common, allocation procedure that distributed the sample budget equally across the alternatives and attributes. We found the allocation procedures that were developed based on the inclusion of decision-maker knowledge, such as knowledge of the decision model, outperformed those that neglected such information. Beginning with general knowledge of the attribute values provided by Bayesian prior distributions, and updating this knowledge with each observed sample, the sequential allocation procedure performed particularly well. These observations demonstrate that managing projects focused on a selection decision so that the decision modeling and the experimental planning are done jointly, rather than in isolation, can improve the overall selection results.

Quantification of the effects of architectural traits on dry mass production and light interception of tomato canopy under different temperature regimes using a dynamic functional-structural plant model

There is increasing interest in evaluating the environmental effects on crop architectural traits and yield improvement. However, crop models describing the dynamic changes in canopy structure with environmental conditions and the complex interactions between canopy structure, light interception, and dry mass production are only gradually emerging. Using tomato (Solanum lycopersicum L.) as a model crop, a dynamic functional-structural plant model (FSPM) was constructed, parameterized, and evaluated to analyse the effects of temperature on architectural traits, which strongly influence canopy light interception and shoot dry mass. The FSPM predicted the organ growth, organ size, and shoot dry mass over time with high accuracy (>85%). Analyses of this FSPM showed that, in comparison with the reference canopy, shoot dry mass may be affected by leaf angle by as much as 20%, leaf curvature by up to 7%, the leaf length: width ratio by up to 5%, internode length by up to 9%, and curvature ratios and leaf arrangement by up to 6%. Tomato canopies at low temperature had higher canopy density and were more clumped due to higher leaf area and shorter internodes. Interestingly, dry mass production and light interception of the clumped canopy were more sensitive to changes in architectural traits. The complex interactions between architectural traits, canopy light interception, dry mass production, and environmental conditions can be studied by the dynamic FSPM, which may serve as a tool for designing a canopy structure which is 'ideal' in a given environment.

A deformation model of flexible, high area-to-mass ratio debris under perturbations and validation method

A new type of space debris was recently discovered by Schildknecht in near -geosynchronous orbit (GEO). These objects were later identified as exhibiting properties associated with High Area-to-Mass ratio (HAMR) objects. According to their brightness magnitudes (light curve), high rotation rates and composition properties (albedo, amount of specular and diffuse reflection, colour, etc), it is thought that these objects are multilayer insulation (MLI). Observations have shown that this debris type is very sensitive to environmental disturbances, particularly solar radiation pressure, due to the fact that their shapes are easily deformed leading to changes in the Area-to-Mass ratio (AMR) over time. This thesis proposes a simple effective flexible model of the thin, deformable membrane with two different methods. Firstly, this debris is modelled with Finite Element Analysis (FEA) by using Bernoulli-Euler theory called “Bernoulli model”. The Bernoulli model is constructed with beam elements consisting 2 nodes and each node has six degrees of freedom (DoF). The mass of membrane is distributed in beam elements. Secondly, the debris based on multibody dynamics theory call “Multibody model” is modelled as a series of lump masses, connected through flexible joints, representing the flexibility of the membrane itself. The mass of the membrane, albeit low, is taken into account with lump masses in the joints. The dynamic equations for the masses, including the constraints defined by the connecting rigid rod, are derived using fundamental Newtonian mechanics. The physical properties of both flexible models required by the models (membrane density, reflectivity, composition, etc.), are assumed to be those of multilayer insulation. Both flexible membrane models are then propagated together with classical orbital and attitude equations of motion near GEO region to predict the orbital evolution under the perturbations of solar radiation pressure, Earth’s gravity field, luni-solar gravitational fields and self-shadowing effect. These results are then compared to two rigid body models (cannonball and flat rigid plate). In this investigation, when comparing with a rigid model, the evolutions of orbital elements of the flexible models indicate the difference of inclination and secular eccentricity evolutions, rapid irregular attitude motion and unstable cross-section area due to a deformation over time. Then, the Monte Carlo simulations by varying initial attitude dynamics and deformed angle are investigated and compared with rigid models over 100 days. As the results of the simulations, the different initial conditions provide unique orbital motions, which is significantly different in term of orbital motions of both rigid models. Furthermore, this thesis presents a methodology to determine the material dynamic properties of thin membranes and validates the deformation of the multibody model with real MLI materials. Experiments are performed in a high vacuum chamber (10-4 mbar) replicating space environment. A thin membrane is hinged at one end but free at the other. The free motion experiment, the first experiment, is a free vibration test to determine the damping coefficient and natural frequency of the thin membrane. In this test, the membrane is allowed to fall freely in the chamber with the motion tracked and captured through high velocity video frames. A Kalman filter technique is implemented in the tracking algorithm to reduce noise and increase the tracking accuracy of the oscillating motion. The forced motion experiment, the last test, is performed to determine the deformation characteristics of the object. A high power spotlight (500-2000W) is used to illuminate the MLI and the displacements are measured by means of a high resolution laser sensor. Finite Element Analysis (FEA) and multibody dynamics of the experimental setups are used for the validation of the flexible model by comparing with the experimental results of displacements and natural frequencies.

The suppliers selection problem: a case study

The effective supplier evaluation and purchasing processes are of vital importance to business organizations, making the suppliers selection problem a fundamental key issue to their success. We consider a complex supplier selection problem with multiple products where minimum package quantities, minimum order values related to delivery costs, and discounted pricing schemes are taken into account. Our main contribution is to present a mixed integer linear programming (MILP) model for this supplier selection problem. The model is used to solve several examples including three real case studies from an electronic equipment assembly company.