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.

Anger and depression predict hospital use among chronic heart failure patients

Costly hospital readmissions among chronic heart failure (CHF) patients are expected to increase dramatically with the ageing population. This study investigated the prognostic ability of depression, anger and anxiety, prospectively, and after adjusting for illness severity, on the number of readmissions to hospital and the total length of stay over one year. Participants comprised 175 inpatients with CHF. Depression, anger, anxiety, and illness severity were measured at baseline. One year later, the number of readmissions and length of stay for each patient were obtained from medical records. Depression and anger play a detrimental role in the health profile of CHF patients.

Complex modelling of open system design for sustainable architecture

This paper argues a model of complex system design for sustainable architecture within a framework of entropy evolution. The spectrum of sustainable architecture consists of the efficient use of energy and material resource in life-cycle of buildings, the active involvement of the occupants in micro-climate control within buildings, and the natural environmental context. The interactions of the parameters compose a complex system of sustainable architectural design, of which the conventional linear and fragmented design technologies are insufficient to indicate holistic and ongoing environmental performance. The complexity theory of dissipative structure states a microscopic formulation of open system evolution, which provides a system design framework for the evolution of building environmental performance towards an optimization of sustainability in architecture.

Bushfire responsive architecture : strategies for reconciling bushfire and biodiversity with daily life

My perspective on the problems associated with building in bushfire prone landscapes comes from 12 years of study of the biophysical and cultural landscapes in the Great Southern Region of WA which resulted in the design and construction of the ‘Hhouse’ at Bremer Bay. The house was developed using a ‘ground up’ approach whereby I conducted a topographical survey and worked with a local botanist and a bushfire risk consultant to ascertain the level of threat that fire presented to this particular site. My intention from the outset however, was not to design a bushfire resistant house per se, but to develop a design which would place the owners in close proximity to the highly biodiverse heath vegetation of the site. I was also seeking a means—through architectural design—of linking the patterns of usage of the house with other site specific conditions related to the prevailing winds, solar orientation and seasonal change.

The modern movement architecture of four South African cities

South Africa's modern architecture is not confined to the cities, but the ideas of the movement were mostly disseminated by architects and academics in Johannesburg, Pretoria, Durban and Cape Town, its four major urban centres. The lay out of significant areas of each city was also influenced by international modernist plans. In outlining the achievements and innovative designs of architects in these cities between the 1930s and 1970s, this article draws a picture of the importance of modernism in South African urban space, and of its diversity. It also draws attention to the political nature of the South African landscape and space, where modernist design was used for racial purposes, and to past and present conservation ideologies. The second part of the article concerns the conservation of modern buildings in these centres; it quotes bibliographies and lists the registers, those existing or under construction. It concludes with an overview of the conservation legislation in place and the challenges of conservation in a context of changing cultural values.

Rhetoric of landscape architecture and interior design discourses : preparation for cross-disciplinary practice

The rhetoric of the pedagogic discourses of landscape architectural students and interior design students is described as part of a doctoral study undertaken to document practices and orientations prior to cross-disciplinary collaboration. We draw on the theoretical framework of Basil Bernstein, an educational sociologist, and the rhetorical method of Kenneth Burke, a literary dramatist, to study the grammars of ‘landscape’ representation employed within these disciplinary examples. We investigate how prepared final year students are for working in a cross-disciplinary manner. The discursive interactions of their work, as illustrated by four examples of drawn images and written text, are described. Our findings suggest that we need to concern ourselves aspects of our pedagogic discourse that brings uniqueness and value to our disciplines ,as well as that shared discourses between disciplines.

Victoria regia's bequest to modern architecture

This paper will explore the relationship between the giant South American waterlily, the Victoria regia (today named Victoria amazonica), and the 1914 Glashaus exposition building by the German architect, Bruno Taut. Starting with a general botanical introduction of Victoria regia, the paper exposes the first European cultivation of the lily by Joseph Paxton at Chatsworth,England, in 1849. Following this initial cultivation, Paxton subsequently develops a specialist greenhouse for the plant, that later becomes the prototype for all Victoria regia greenhouses. However, from about 1860 as Victoria regia cultivation spreads to continental Europe, a greenhouse that differs from Paxton’s prototype subsequently evolves. An investigation of these later continental European greenhouses, coupled with an exposure of Taut’s own writings concerning Victoria regia, reveals startling similarities to the Glashaus, which ultimately reveals the Glashaus as directly inspired by Victoria regia.

Cluster-based Intrusion Detection (CBID) architecture for mobile ad hoc networks

The ad hoc networks are vulnerable to attacks due to distributed nature and lack of infrastructure. Intrusion detection systems (IDS) provide audit and monitoring capabilities that offer the local security to a node and help to perceive the specific trust level of other nodes. The clustering protocols can be taken as an additional advantage in these processing constrained networks to collaboratively detect intrusions with less power usage and minimal overhead. Existing clustering protocols are not suitable for intrusion detection purposes, because they are linked with the routes. The route establishment and route renewal affects the clusters and as a consequence, the processing and traffic overhead increases due to instability of clusters. The ad hoc networks are battery and power constraint, and therefore a trusted monitoring node should be available to detect and respond against intrusions in time. This can be achieved only if the clusters are stable for a long period of time. If the clusters are regularly changed due to routes, the intrusion detection will not prove to be effective. Therefore, a generalized clustering algorithm has been proposed that can run on top of any routing protocol and can monitor the intrusions constantly irrespective of the routes. The proposed simplified clustering scheme has been used to detect intrusions, resulting in high detection rates and low processing and memory overhead irrespective of the routes, connections, traffic types and mobility of nodes in the network. Clustering is also useful to detect intrusions collaboratively since an individual node can neither detect the malicious node alone nor it can take action against that node on its own.

Charles and Camilla Chair

The seat is an externally fixed seat for the public located at the entrance to the Prince Charles Hospital. The form of the seat is designed specifically for two, to celebrate the marriage of Charles and Camilla. The design of bench structure represents the Southern Cross which is predominant in our night sky, distinguishing us in location from Charles and Camilla, the night of their wedding. The design also incorporates references to undulating forms of the Queensland Landscape.

DDX : A distributed software architecture for robotic systems

The Dynamic Data eXchange (DDX) is our third generation platform for building distributed robot controllers. DDX allows a coalition of programs to share data at run-time through an efficient shared memory mechanism managed by a store. Further, stores on multiple machines can be linked by means of a global catalog and data is moved between the stores on an as needed basis by multi-casting. Heterogeneous computer systems are handled. We describe the architecture of DDX and the standard clients we have developed that let us rapidly build complex control systems with minimal coding.

A secure architecture for Australia’s index based e-health environment

This paper proposes a security architecture for the basic cross indexing systems emerging as foundational structures in current health information systems. In these systems unique identifiers are issued to healthcare providers and consumers. In most cases, such numbering schemes are national in scope and must therefore necessarily be used via an indexing system to identify records contained in pre-existing local, regional or national health information systems. Most large scale electronic health record systems envisage that such correlation between national healthcare identifiers and pre-existing identifiers will be performed by some centrally administered cross referencing, or index system. This paper is concerned with the security architecture for such indexing servers and the manner in which they interface with pre-existing health systems (including both workstations and servers). The paper proposes two required structures to achieve the goal of a national scale, and secure exchange of electronic health information, including: (a) the employment of high trust computer systems to perform an indexing function, and (b) the development and deployment of an appropriate high trust interface module, a Healthcare Interface Processor (HIP), to be integrated into the connected workstations or servers of healthcare service providers. This proposed architecture is specifically oriented toward requirements identified in the Connectivity Architecture for Australia’s e-health scheme as outlined by NEHTA and the national e-health strategy released by the Australian Health Ministers.

Applying environmentally responsive characteristics of vernacular architecture to sustainable housing in Vietnam

Over many centuries of settlement, Vietnamese inhabitants have developed a vernacular architecture that is well adapted to the region’s climatic and topographical conditions. Vernacular Vietnamese housing uses natural systems to create a built environment that integrates well with nature. The vernacular combines site-sensitive, passive solar design, natural materials and appropriate structure to achieve harmony among nature, humans and the built environment. Unfortunately, these unique features have not been applied in contemporary Vietnamese architecture, which displays energy-intensive materials and built forms. This research is analysing how environmentally-responsive elements of vernacular architecture could be applied to modern sustainable housing in Vietnam. Elements of many types of vernacular architecture throughout the country are reviewed as precedents for future building planning and design. The paper also looks at culturally and ecologically appropriate legislative and voluntary options for encouraging more sustainable housing.

Improved functional ability and independence in activities of daily living for older adults at high risk of hospital readmission : a randomised controlled trial

Objective: During hospitalisation older people often experience functional decline which impacts on their future independence. The objective of this study was to evaluate a multifaceted transitional care intervention including home-based exercise strategies for at-risk older people on functional status, independence in activities of daily living, and walking ability. Methods: A randomised controlled trial was undertaken in a metropolitan hospital in Australia with 128 patients (64 intervention, 64 control) aged over 65 years with an acute medical admission and at least one risk factor for hospital readmission. The intervention group received an individually tailored program for exercise and follow-up care which was commenced in hospital and included regular visits in hospital by a physiotherapist and a Registered Nurse, a home visit following discharge, and regular telephone follow-up for 24 weeks following discharge. The program was designed to improve health promoting behaviours, strength, stability, endurance and mobility. Data were collected at baseline, then 4, 12 and 24 weeks following discharge using the Index of Activities of Daily Living (ADL), Instrumental Index of Activities of Daily Living (IADL), and the Walking Impairment Questionnaire (Modified). Results: Significant improvements were found in the intervention group in IADL scores (p<.001), ADL scores (p<.001), and WIQ scale scores (p<.001) in comparison to the control group. The greatest improvements were found in the first four weeks following discharge. Conclusions: Early introduction of a transitional model of care incorporating a tailored exercise program and regular telephone follow-up for hospitalised at-risk older adults can improve independence and functional ability.

The effects of pore architecture in silk fibroin scaffolds on the growth and differentiation of mesenchymal stem cells expressing BMP7

The pore architecture of scaffolds is known to play a critical role in tissue engineering as it provides the vital framework for seeded cells to organize into a functioning tissue. In this report we have investigated the effects of different concentrations of silk fibroin protein on three-dimensional (3D) scaffold pore microstructure. Four pore size ranges of silk fibroin scaffolds were made by the freeze drying technique, with the pore sizes ranging from 50 to 300 lm. The pore sizes of the scaffolds decreased as the concentration of fibroin protein increased. Human bone marrow mesenchymal stromal cells (BMSC) transfected with the BMP7 gene were cultured in these scaffolds. A cell viability colorimetric assay, alkaline phosphatase assay and reverse transcription-polymerase chain reaction were performed to analyze the effect of pore size on cell growth, the secretion of extracellular matrix (ECM) and osteogenic differentiation. Cell migration in 3D scaffolds was confirmed by confocal microscopy. Calvarial defects in SCID mice were used to determine the bone forming ability of the silk fibroin scaffolds incorporating BMSC expressing BMP7. The results showed that BMSC expressing BMP7 preferred a pore size between 100 and 300 lm in silk fibroin protein fabricated scaffolds, with better cell proliferation and ECM production. Furthermore, in vivo transplantation of the silk fibroin scaffolds combined with BMSC expressing BMP7 induced new bone formation. This study has shown that an optimized pore architecture of silk fibroin scaffolds can modulate the bioactivity of BMP7-transfected BMSC in bone formation.

The relationship between particulate air pollution and emergency hospital visits for hypertension in Beijing, China

BACKGROUND: A number of epidemiological studies have examined the adverse effect of air pollution on mortality and morbidity. Also, several studies have investigated the associations between air pollution and specific-cause diseases including arrhythmia, myocardial infarction, and heart failure. However, little is known about the relationship between air pollution and the onset of hypertension. OBJECTIVE: To explore the risk effect of particulate matter air pollution on the emergency hospital visits (EHVs) for hypertension in Beijing, China. METHODS: We gathered data on daily EHVs for hypertension, fine particulate matter less than 2.5 microm in aerodynamic diameter (PM(2.5)), particulate matter less than 10 microm in aerodynamic diameter (PM(10)), sulfur dioxide, and nitrogen dioxide in Beijing, China during 2007. A time-stratified case-crossover design with distributed lag model was used to evaluate associations between ambient air pollutants and hypertension. Daily mean temperature and relative humidity were controlled in all models. RESULTS: There were 1,491 EHVs for hypertension during the study period. In single pollutant models, an increase in 10 microg/m(3) in PM(2.5) and PM(10) was associated with EHVs for hypertension with odds ratios (overall effect of five days) of 1.084 (95% confidence interval (CI): 1.028, 1.139) and 1.060% (95% CI: 1.020, 1.101), respectively. CONCLUSION: Elevated levels of ambient particulate matters are associated with an increase in EHVs for hypertension in Beijing, China.