Economics and preventing healthcare acquired infection

The evolution of organisms that cause healthcare acquired infections (HAI) puts extra stress on hospitals already struggling with rising costs and demands for greater productivity and cost containment. Infection control can save scarce resources, lives, and possibly a facility’s reputation, but statistics and epidemiology are not always sufficient to make the case for the added expense. Economics and Preventing Healthcare Acquired Infection presents a rigorous analytic framework for dealing with this increasingly serious problem. ----- Engagingly written for the economics non-specialist, and brimming with tables, charts, and case examples, the book lays out the concepts of economic analysis in clear, real-world terms so that infection control professionals or infection preventionists will gain competence in developing analyses of their own, and be confident in the arguments they present to decision-makers. The authors: ----- Ground the reader in the basic principles and language of economics. ----- Explain the role of health economists in general and in terms of infection prevention and control. ----- Introduce the concept of economic appraisal, showing how to frame the problem, evaluate and use data, and account for uncertainty. ----- Review methods of estimating and interpreting the costs and health benefits of HAI control programs and prevention methods. ----- Walk the reader through a published economic appraisal of an infection reduction program. ----- Identify current and emerging applications of economics in infection control. ---- Economics and Preventing Healthcare Acquired Infection is a unique resource for practitioners and researchers in infection prevention, control and healthcare economics. It offers valuable alternate perspective for professionals in health services research, healthcare epidemiology, healthcare management, and hospital administration. ----- Written for: Professionals and researchers in infection control, health services research, hospital epidemiology, healthcare economics, healthcare management, hospital administration; Association of Professionals in Infection Control (APIC), Society for Healthcare Epidemiologists of America (SHEA)

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

A comparative study of the effect of calibration conditions on the water equivalence of a range of gel dosimeters

Gel dosimeters are of increasing interest in the field of radiation oncology as the only truly three-dimensional integrating radiation dosimeter. There are a range of ferrous-sulphate and polymer gel dosimeters. To be of use, they must be water-equivalent. On their own, this relates to their radiological properties as determined by their composition. In the context of calibration of gel dosimeters, there is the added complexity of the calibration geometry; the presence of containment vessels may influence the dose absorbed. Five such methods of calibration are modelled here using the Monte Carlo method. It is found that the Fricke gel best matches water for most of the calibration methods, and that the best calibration method involves the use of a large tub into which multiple fields of different dose are directed. The least accurate calibration method involves the use of a long test tube along which a depth dose curve yields multiple calibration points.

A comparative study of the effect of calibration conditions on the water equivalence of a range of gel dosimeters

Gel dosimeters are of increasing interest in the field of radiation oncology as the only truly three-dimensional integrating radiation dosimeter. There are a range of ferrous-sulphate and polymer gel dosimeters. To be of use, they must be water-equivalent. On their own, this relates to their radiological properties as determined by their composition. In the context of calibration of gel dosimeters, there is the added complexity of the calibration geometry; the presence of containment vessels may influence the dose absorbed. Five such methods of calibration are modelled here using the Monte Carlo method. It is found that the Fricke gel best matches water for most of the calibration methods, and that the best calibration method involves the use of a large tub into which multiple fields of different dose are directed. The least accurate calibration method involves the use of a long test tube along which a depth dose curve yields multiple calibration points.

Detaining the usual suspects : charting the use of segregated settings in New South Wales government schools, Australia

In this paper, we examine the increase in segregated placements in the New South Wales government school sector. Using disaggregated enrolment data, we point to the growing over-representation of boys in special schools and classes; particularly those of a certain age in certain support categories. In the discussion that follows, we question the role of special education in the development of new and additional forms of being “at risk.” In effect, we invert the traditional concept by asking: Who is at risk of what? In focusing on the containment of risk, are modern practices of diagnosis and segregation perpetuating risks that already disproportionately affect certain groups of individuals? Do these perceptions of and responses to risk in local schools now place these students at greater personal risk of school failure and a future marked by social exclusion? And, finally, is that risk worth the cost?

Tangled Webs : Using Bayesian Networks in the Fight Against Infection

Bayesian networks (BNs) provide a statistical modelling framework which is ideally suited for modelling the many factors and components of complex problems such as healthcare-acquired infections. The methicillin-resistant Staphylococcus aureus (MRSA) organism is particularly troublesome since it is resistant to standard treatments for Staph infections. Overcrowding and understa�ng are believed to increase infection transmission rates and also to inhibit the effectiveness of disease control measures. Clearly the mechanisms behind MRSA transmission and containment are very complicated and control strategies may only be e�ective when used in combination. BNs are growing in popularity in general and in medical sciences in particular. A recent Current Content search of the number of published BN journal articles showed a fi�ve fold increase in general and a six fold increase in medical and veterinary science from 2000 to 2009. This chapter introduces the reader to Bayesian network (BN) modelling and an iterative modelling approach to build and test the BN created to investigate the possible role of high bed occupancy on transmission of MRSA while simultaneously taking into account other risk factors.

The discursive nature of citizenship : Indigenous sovereign rights, racism and welfare reform

Citizenship is more than a status associated with a bundle of rights; it is also the formal contract by which the sovereignty of a nation is extended to the individual in exchange for being governed. Who can and who cannot contract into this status and what rights are able to be exercised is also shaped by who possesses the nation. In this article it is argued that citizenship operates discursively to contain Indigenous people’s engagement with the economy through social rights. This containment precludes consideration of Indigenous sovereign rights to our lands and resources, to enable Indigenous economic development within a capitalist market economy.

From expert to tasks, expert nursing practice redefined?

Aim The aim of this paper was to explore the concept of expertise in nursing from the perspective of how it relates to current driving forces in health care in which it discusses the potential barriers to acceptance of nursing expertise in a climate in which quantification of value and cost containment run high on agendas. Background Expert nursing practice can be argued to be central to high quality, holistic, individualized patient care. However, changes in government policy which have led to the inception of comprehensive guidelines or protocols of care are in danger of relegating the ‘expert nurse’ to being an icon of the past. Indeed, it could be argued that expert nurses are an expensive commodity within the nursing workforce. Consequently, with this change to the use of clinical guidelines, it calls into question how expert nursing practice will develop within this framework of care. Method The article critically reviews the evidence related to the role of the Expert Nurse in an attempt to identify the key concepts and ideas, and how the inception of care protocols has implications for their role. Conclusion Nursing expertise which focuses on the provision of individualized, holistic care and is based largely on intuitive decision making cannot, should not be reduced to being articulated in positivist terms. However, the dominant power and decision-making focus in health care means that nurses must be confident in articulating the value of a concept which may be outside the scope of knowledge of those with whom they are debating. Relevance to clinical practice The principles of abduction or fuzzy logic may be useful in assisting nurses to explain in terms which others can comprehend, the value of nursing expertise.

Defining the expert ICU nurse

This paper explores the concept of expertise in intensive care nursing practice from the perspective of its relationship to the current driving forces in healthcare. It discusses the potential barriers to acceptance of nursing expertise in a climate in which quantification of value and cost containment run high on agendas. It argues that nursing expertise which focuses on the provision of individualised, holistic care and which is based largely on intuitive decision-making cannot and should not be reduced to being articulated in positivist terms. The principles of abduction or fuzzy logic, derived from computer science, may be useful in assisting nurses to explain in terms, which others can comprehend, the value of nursing expertise.

The IHR (2005), disease surveillance, and the individual in global health politics

Since the revisions to the International Health Regulations (IHR) in 2005, much attention has turned to two concerns relating to infectious disease control. The first is how to assist states to strengthen their capacity to identify and verify public health emergencies of international concern (PHEIC). The second is the question of how the World Health Organization (WHO) will operate its expanded mandate under the revised IHR. Very little attention has been paid to the potential individual power that has been afforded under the IHR revisions – primarily through the first inclusion of human rights principles into the instrument and the allowance for the WHO to receive non-state surveillance intelligence and informal reports of health emergencies. These inclusions mark the individual as a powerful actor, but also recognise the vulnerability of the individual to the whim of the state in outbreak response and containment. In this paper we examine why these changes to the IHR occurred and explore the consequence of expanding the sovereignty-as-responsibility concept to disease outbreak response. To this end our paper considers both the strengths and weaknesses of incorporating reports from non-official sources and including human rights principles in the IHR framework.

The Healthy Trends of International Relations Research

As the end of the Cold War approached in 1989, Caroline Thomas argued: “It is important that the discipline [International Relations, IR] should address the issue of disease and more broadly, health, not simply to facilitate containment of disease transmission across international borders but also because central notions of justice, equity, efficiency and order are involved” (1989:273).1 Ten years later, Craig Murphy echoed these sentiments. Murphy (2001: 352) proposed that IR had yet to grapple with the political consequences of growing inequality between the world’s rich and poor, and areas such as health—where these inequalities were most stark—should become the field’s core business. How IR’s theories and methods would approach these issues was less clear. Bettcher and Yach (1998) cautioned that IR would be unable to develop progressive research projects that explored global health diplomacy as a global public good without adopting new perspectives and methods. Others warned that the expansion of security studies into areas such as global health would weaken the intellectual coherency of the field (Walt 1991:213). Taking its cue from the recent Ng and Prah Ruger (2011) study, this paper returns to these concerns to briefly explore key trends and potential future concerns of research in IR on health...

Securitizing infectious disease

Over the past decade there has been an increased awareness in the field of international relations of the potential impact of an infectious disease epidemic on national security. While states’ attempts to combat infectious disease have a long history, what is new in this area is the adoption at the international level of securitized responses regarding the containment of infectious disease. This article argues that the securitization of infectious disease by states and the World Health Organization (WHO) has led to two key developments. First, the WHO has had to assert itself as the primary actor that all states, particularly western states, can rely upon to contain the threat of infectious diseases. The WHO's apparent success in this is evidenced by the development of the Global Outbreak Alert Response Network (GOARN), which has led to arguments that the WHO has emerged as the key authority in global health governance. The second outcome that this article seeks to explore is the development of the WHO's authority in the area of infectious disease surveillance. In particular, is GOARN a representation of the WHO's consummate authority in the area of coordinating infectious disease response or is GOARN the product of the WHO's capitulation to western states’ concerns with preventing infectious disease outbreaks from reaching their borders and as a result, are arguments expressing the authority of the WHO in infectious disease response premature?

Electron tomography reveals the steps in filovirus budding

The filoviruses, Marburg and Ebola, are non-segmented negative-strand RNA viruses causing severe hemorrhagic fever with high mortality rates in humans and nonhuman primates. The sequence of events that leads to release of filovirus particles from cells is poorly understood. Two contrasting mechanisms have been proposed, one proceeding via a "submarine-like" budding with the helical nucleocapsid emerging parallel to the plasma membrane, and the other via perpendicular "rocketlike" protrusion. Here we have infected cells with Marburg virus under BSL-4 containment conditions, and reconstructed the sequence of steps in the budding process in three dimensions using electron tomography of plastic-embedded cells. We find that highly infectious filamentous particles are released at early stages in infection. Budding proceeds via lateral association of intracellular nucleocapsid along its whole length with the plasma membrane, followed by rapid envelopment initiated at one end of the nucleocapsid, leading to a protruding intermediate. Scission results in local membrane instability at the rear of the virus. After prolonged infection, increased vesiculation of the plasma membrane correlates with changes in shape and infectivity of released viruses. Our observations demonstrate a cellular determinant of virus shape. They reconcile the contrasting models of filovirus budding and allow us to describe the sequence of events taking place during budding and release of Marburg virus. We propose that this represents a general sequence of events also followed by other filamentous and rod-shaped viruses.

Priority threat management of invasive plant species in the Lake Eyre Basin

This project is led by scientists in conservation decision appraisal and brings together a group of experts working across the Lake Eyre Basin (LEB). The LEB covers a sixth of Australia, with an array of globally significant natural values that are threatened by invasive plants, among other things. Managers at various levels are investing in attempts to control, contain and eradicate these invasive plant species, under severe time and resources limitations. To date there has been no basin-wide assessment of which weed management strategies and locations provide the best investments for maximising outcomes for biodiversity per unit cost. Further, there has been no assessment of the extent of ecosystem intactness that may be lost without effective invasive plant species management strategies. Given that there are insufficient resources to manage all invasive plant species everywhere, this information has the potential to improve current investment decisions. Here, we provide a prioritisation of invasive plant management strategies in the LEB. Prioritisation was based on cost-effectiveness for biodiversity benefits. We identify the key invasive plant species to target to protect ecosystem intactness across the bioregions of the LEB, the level of investment required and the likely reduction in invasive species dominance gained per dollar spent on each strategy. Our focus is on strategies that are technically and socially feasible and reduce the likelihood that high impact invasive plant species will dominate native ecosystems, and therefore change their form and function. The outputs of this work are designed to help guide decision-making and further planning and investment in weed management for the Basin. Experts in weed management, policy-making, community engagement, biodiversity and natural values of the Basin, attended a workshop and agreed upon 12 strategies to manage invasive plants. The strategies focused primarily on 10 weeds which were considered to have a high potential for broad, significant impacts on natural ecosystems in the next 50 years and for which feasible management strategies could be defined. Each strategy consisted of one or more supporting actions, many of which were spatially linked to IBRA (Interim Biogeographical Regionalisation of Australia) bioregions. The first strategy was an over-arching recommendation for improved mapping, information sharing, education and extension efforts in order to facilitate the more specific weed management strategies. The 10 more specific weed management strategies targeted the control and/or eradication of the following high-impact exotic plants: mesquite, parkinsonia, rubber vine, bellyache bush, cacti, mother of millions, chinee apple, athel pine and prickly acacia, as well as a separate strategy for eradicating all invasive plants from one key threatened ecological community, the GAB (Great Artesian Basin dependant) mound springs. Experts estimated the expected biodiversity benefit of each strategy as the reduction in area that an invasive plant species is likely to dominate in over a 50-year period, where dominance was defined as more than 30% coverage at a site. Costs were estimated in present day terms over 50 years largely during follow up discussions post workshop. Cost-effectiveness was then calculated for each strategy in each bioregion by dividing the average expected benefit by the average annual costs. Overall, the total cost of managing 12 invasive plant strategies over the next 50 years was estimated at $1.7 billion. It was estimated that implementation of these strategies would result in a reduction of invasive plant dominance by 17 million ha (a potential 32% reduction), roughly 14% of the LEB. If only targeting Weeds of National Significance (WONS), the total cost was estimated to be $113 million over the next 50 years. Over the next 50 years, $2.3 million was estimated to eradicate all invasive plant species from the Great Artesian Basin Mound Springs threatened ecological community. Prevention and awareness programs were another key strategy targeted across the Basin and estimated at $17.5 million in total over 50 years. The cost of controlling, eradicating and containing buffel grass were the most expensive, over $1.5 billion over 50 years; this strategy was estimated to result in a reduction in buffel grass dominance of a million ha in areas where this species is identified as an environmental problem. Buffel grass has been deliberately planted across the Basin for pasture production and is by far the most widely distributed exotic species. Its management is contentious, having economic value to many graziers while posing serious threats to biodiversity and sites of high cultural and conservation interest. The strategy for containing and locally eradicating buffel grass was a challenge to cost based on expert knowledge, possibly because of the dual nature of this species as a valued pastoral grass and environmental weed. Based on our conversations with experts, it appears that control and eradication programs for this species, in conservation areas, are growing rapidly and that information on the most cost-effective strategies for this species will continue to develop over time. The top five most cost-effective strategies for the entire LEB were for the management of: 1) parkinsonia, 2) chinee apple, 3) mesquite, 4) rubber vine and 5) bellyache bush. Chinee apple and mother of millions are not WONS and have comparatively small populations within the semi-arid bioregions of Queensland. Experts felt that there was an opportunity to eradicate these species before they had the chance to develop into high-impact species within the LEB. Prickly acacia was estimated to have one of the highest benefits, but the costs of this strategy were high, therefore it was ranked 7th overall. The buffel grass strategy was ranked the lowest (10th) in terms of cost effectiveness. The top five most cost-effective strategies within and across the bioregions were the management of: 1) parkinsonia in the Channel Country, 2) parkinsonia in the Desert Uplands, 3) mesquite in the Mitchell Grass Downs, 4) parkinsonia in the Mitchell Grass Downs, and 5) mother of millions in the Desert Uplands. Although actions for several invasive plant species like parkinsonia and prickly acacia were concentrated in the Queensland part of the LEB, the actions involved investing in containment zones to prevent the spread of these species into other states. In the NT and SA bioregions of the LEB, the management of athel pine, parkinsonia and cacti were the main strategies. While outside the scientific research goals of study, this work highlighted a number of important incidental findings that led us to make the following recommendations for future research and implementation of weed management in the Basin: • Ongoing stakeholder engagement, extension and participation is required to ensure this prioritisation effort has a positive impact in affecting on-ground decision making and planning. • Short term funding for weed management was identified as a major reason for failure of current efforts, hence future funding needs to be secure and ongoing. • Improved mapping and information sharing is essential to implement effective weed management. • Due to uncertainties in the outcomes and impacts of management options, strategies should be implemented as part of an adaptive management program. The information provided in this report can be used to guide investment for controlling high-impact invasive plant species for the benefits of biodiversity conservation. We do not present a final prioritisation of invasive plant strategies for the LEB, and we have not addressed the cultural, socio-economic or spatial components necessary for an implementation plan. Cost-effectiveness depends on the objectives used; in our case we used the intactness of ecosystems as a surrogate for expected biodiversity benefits, measured by the extent that each invasive plant species is likely to dominate in a bioregion. When other relevant factors for implementation are considered the priorities may change and some actions may not be appropriate in some locations. We present the costs, ecological benefits and cost-effectiveness of preventing, containing, reducing and eradicating the dominance of high impact invasive plants through realistic management actions over the next 50 years. In doing so, we are able to estimate the size of the weed management problem in the LEB and provide expert-based estimates of the likely outcomes and benefits of implementing weed management strategies. The priorities resulting from this work provide a prospectus for guiding further investment in management and in improving information availability.

Optimizing search strategies for invasive pests: Learn before you leap

Strategic searching for invasive pests presents a formidable challenge for conservation managers. Limited funding can necessitate choosing between surveying many sites cursorily, or focussing intensively on fewer sites. While existing knowledge may help to target more likely sites, e.g. with species distribution models (maps), this knowledge is not flawless and improving it also requires management investment. 2.In a rare example of trading-off action against knowledge gain, we combine search coverage and accuracy, and its future improvement, within a single optimisation framework. More specifically we examine under which circumstances managers should adopt one of two search-and-control strategies (cursory or focussed), and when they should divert funding to improving knowledge, making better predictive maps that benefit future searches. 3.We use a family of Receiver Operating Characteristic curves to reflect the quality of maps that direct search efforts. We demonstrate our framework by linking these to a logistic model of invasive spread such as that for the red imported fire ant Solenopsis invicta in south-east Queensland, Australia. 4.Cursory widespread searching is only optimal if the pest is already widespread or knowledge is poor, otherwise focussed searching exploiting the map is preferable. For longer management timeframes, eradication is more likely if funds are initially devoted to improving knowledge, even if this results in a short-term explosion of the pest population. 5.Synthesis and applications. By combining trade-offs between knowledge acquisition and utilization, managers can better focus - and justify - their spending to achieve optimal results in invasive control efforts. This framework can improve the efficiency of any ecological management that relies on predicting occurrence. © 2010 The Authors. Journal of Applied Ecology © 2010 British Ecological Society.