The Implications of Activity Based Funding for Emergency Departments : A Comprehensive Literature Review

Executive Summary Emergency Departments (EDs) locally, nationally and internationally are becoming increasingly busy. Within this context, it can be challenging to deliver a health service that is safe, of high quality and cost-effective. Whilst various models are described within the literature that aim to measure ED ‘work’ or ‘activity’, they are often not linked to a measure of costs to provide such activity. It is important for hospital and ED managers to understand and apply this link so that optimal staffing and financial resourcing can be justifiably sought. This research is timely given that Australia has moved towards a national Activity Based Funding (ABF) model for ED activity. ABF is believed to increase transparency of care and fairness (i.e. equal work receives equal pay). ABF involves a person-, performance- or activity-based payment system, and thus a move away from historical “block payment” models that do not incentivise efficiency and quality. The aim of the Statewide Workforce and Activity-Based Funding Modelling Project in Queensland Emergency Departments (SWAMPED) is to identify and describe best practice Emergency Department (ED) workforce models within the current context of ED funding that operates under an ABF model. The study is comprised of five distinct phases. This monograph (Phase 1) comprises a systematic review of the literature that was completed in June 2013. The remaining phases include a detailed survey of Queensland hospital EDs’ resource levels, activity and operational models of care, development of new resource models, development of a user-friendly modelling interface for ED mangers, and production of a final report that identifies policy implications. The anticipated deliverable outcome of this research is the development of an ABF based Emergency Workforce Modelling Tool that will enable ED managers to profile both their workforce and operational models of care. Additionally, the tool will assist with the ability to more accurately inform adequate staffing numbers required in the future, inform planning of expected expenditures and be used for standardisation and benchmarking across similar EDs. Summary of the Findings Within the remit of this review of the literature, the main findings include: 1. EDs are becoming busier and more congested Rising demand, barriers to ED throughput and transitions of care all contribute to ED congestion. In addition requests by organisational managers and the community require continued broadening of the scope of services required of the ED and further increases in demand. As the population live longer with more lifestyle diseases their propensity to require ED care continues to grow. 2. Various models of care within EDs exist Models often vary to account for site specific characteritics to suit staffing profile, ED geographical location (e.g. metropolitan or rural site), and patient demographic profile (e.g. paediatrics, older persons, ethnicity). Existing and new models implemented within EDs often depend on the target outcome requiring change. Generally this is focussed on addressing issues at the input, throughput or output areas of the ED. Even with models targeting similar demographic or illness, the structure and process elements underpinning the model can vary, which can impact on outcomes and variance to the patient and carer experience between and within EDs. Major models of care to manage throughput inefficiencies include: A. Workforce Models of Care focus on the appropriate level of staffing for a given workload to provide prompt, timely and clinically effective patient care within an emergency care setting. The studies reviewed suggest that the early involvement of senior medical decision maker and/or specialised nursing roles such as Emergency Nurse Practitioners and Clinical Initiatives Nurse, primary contact or extended scope Allied Health Practitioners can facilitate patient flow and improve key indicators such as length of stay and reducing the number of those who did not wait to be seen amongst others. B. Operational Models of Care within EDs focus on mechanisms for streaming (e.g. fast-tracking) or otherwise grouping patient care based on acuity and complexity to assist with minimising any throughput inefficiencies. While studies support the positive impact of these models in general, it appears that they are most effective when they are adequately resourced. 3. Various methods of measuring ED activity exist Measuring ED activity requires careful consideration of models of care and staffing profile. Measuring activity requires the ability to account for factors including: patient census, acuity, LOS, intensity of intervention, department skill-mix plus an adjustment for non-patient care time. 4. Gaps in the literature Continued ED growth calls for new and innovative care delivery models that are safe, clinically effective and cost effective. New roles and stand-alone service delivery models are often evaluated in isolation without considering the global and economic impact on staffing profiles. Whilst various models of accounting for and measuring health care activity exist, costing studies and cost effectiveness studies are lacking for EDs making accurate and reliable assessments of care models difficult. There is a necessity to further understand, refine and account for measures of ED complexity that define a workload upon which resources and appropriate staffing determinations can be made into the future. There is also a need for continued monitoring and comprehensive evaluation of newly implemented workforce modelling tools. This research acknowledges those gaps and aims to: • Undertake a comprehensive and integrated whole of department workforce profiling exercise relative to resources in the context of ABF. • Inform workforce requirements based on traditional quantitative markers (e.g. volume and acuity) combined with qualitative elements of ED models of care; • Develop a comprehensive and validated workforce calculation tool that can be used to better inform or at least guide workforce requirements in a more transparent manner.

Ultraviolet Photodissociation of the N-Methylpyridinium Ion: Action Spectroscopy and Product Characterization

The ultraviolet photodissociation of gas-phase N-methylpyridinium ions is studied at room temperature using laser photodissociation mass spectrometry and structurally diagnostic ion-molecule reaction kinetics. The C5H5N-CH3+ (m/z 94), C5H5N-CD3+ (m/z 97), and C5D5N-CH3+(m/z 99) isotopologues are investigated, and it is shown that the N-methylpyridinium ion photodissociates by the loss of methane in the 36 000 - 43 000 cm(-1) (280 - 230 nm) region. The dissociation likely occurs on the ground state surface following internal conversion from the SI state. For each isotopologue, by monitoring the photofragmentation yield as a function of photon wavenumber, a broad vibronically featured band is recorded with origin (0-0) transitions assigned at 38 130, 38 140 and 38 320 cm(-1) for C5H5N-CH3+ C5H5N-CD3+ and C5D5N-CH3+, respectively. With the aid of quantum chemical calculations (CASSCF(6,6)/aug-cc-pVDZ), most of the observed vibronic detail is assigned to two in-plane ring deformation modes. Finally, using ion-molecule reactions, the methane coproduct at m/z 78 is confirmed as a 2-pyridinylium ion.

Ozone-induced dissociation of conjugated lipids reveals significant reaction rate enhancements and characteristic odd-electron product ions

Ozone-induced dissociation (OzID) is an alternative ion activation method that relies on the gas phase ion-molecule reaction between a mass-selected target ion and ozone in an ion trap mass spectrometer. Herein, we evaluated the performance of OzID for both the structural elucidation and selective detection of conjugated carbon-carbon double bond motifs within lipids. The relative reactivity trends for \[M + X](+) ions (where X = Li, Na, K) formed via electrospray ionization (ESI) of conjugated versus nonconjugated fatty acid methyl esters (FAMEs) were examined using two different OzID-enabled linear ion-trap mass spectrometers. Compared with nonconjugated analogues, FAMEs derived from conjugated linoleic acids were found to react up to 200 times faster and to yield characteristic radical cations. The significantly enhanced reactivity of conjugated isomers means that OzID product ions can be observed without invoking a reaction delay in the experimental sequence (i.e., trapping of ions in the presence of ozone is not required). This possibility has been exploited to undertake neutral-loss scans on a triple quadrupole mass spectrometer targeting characteristic OzID transitions. Such analyses reveal the presence of conjugated double bonds in lipids extracted from selected foodstuffs. Finally, by benchmarking of the absolute ozone concentration inside the ion trap, second order rate constants for the gas phase reactions between unsaturated organic ions and ozone were obtained. These results demonstrate a significant influence of the adducting metal on reaction rate constants in the fashion Li > Na > K.

Developing a culture to support peer review of teaching in higher education

This presentation addresses issues related to leadership, academic development and scholarship of teaching and learning, and highlights research funded by the Australian Office of Learning and Teaching (OLT) designed to embed and sustain peer review of teaching within the culture of 5 Australian universities: Queensland University of Technology, University of Technology, Sydney, University of Adelaide, Curtin University, and Charles Darwin University. Peer review of teaching in higher education will be emphasised as a professional process for providing feedback on teaching and learning practice, which if sustained, can become an effective ongoing strategy for academic development (Barnard et al, 2011; Bell, 2005; Bolt and Atkinson, 2010; McGill & Beaty 2001, 1992; Kemmis & McTaggart, 2000). The research affirms that using developmental peer review models (Barnard et al, 2011; D'Andrea, 2002; Hammersley-Fletcher & Orsmond, 2004) can bring about successful implementation, especially when implemented within a distributive leadership framework (Spillane & Healey, 2010). The project’s aims and objectives were to develop leadership capacity and integrate peer review as a cultural practice in higher education. The research design was a two stage inquiry process over 2 years. The project began in July 2011 and encompassed a development and pilot phase followed by a cascade phase with questionnaire and focus group evaluation processes to support ongoing improvement and measures of outcome. Leadership development activities included locally delivered workshops complemented by the identification and support of champions. To optimise long term sustainability, the project was implemented through existing learning and teaching structures and processes within the respective partner universities. Research outcomes highlight the fundamentals of peer review of teaching and the broader contextual elements of integration, leadership and development, expressed as a conceptual model for embedding peer review of teaching within higher education. The research opens a communicative space about introduction of peer review that goes further than simply espousing its worth and introduction. The conceptual model highlights the importance of development of distributive leadership capacity, integration of policies and processes, and understanding the values, beliefs, assumptions and behaviors embedded in an organizational culture. The presentation overviews empirical findings that demonstrate progress to advance peer review requires an ‘across-the-board’ commitment to embed change, and inherently demands a process that co-creates connection across colleagues, discipline groups, and the university sector. Progress toward peer review of teaching as a cultural phenomenon can be achieved and has advantages for academic staff, scholarship, teaching evaluation and an organisation, if attention is given to strategies that influence the contexts and cultures of teaching practice. Peer review as a strategy to develop excellence in teaching is considered from a holistic perspective that by necessity encompasses all elements of an educational environment and has a focus on scholarship of teaching. The work is ongoing and has implication for policy, research, teaching development and student outcomes, and has potential application world-wide.

A question of agency : applying Sen’s theory of human capability to the concept of secondary school student career ‘choice’

In this paper, we seek to operationalize Amartya Sen's concept of human capability to guide a scholarly investigation of student career choice capability. We begin by outlining factors affecting youth labour markets in Australia; a prosperous country that is affected by a ‘two-speed’ national economy. We then examine recent government initiatives that have been designed to combat youth unemployment and cyclical disadvantage by enhancing the aspirations and career knowledge of secondary school students. We argue that these policy measures are based on four assumptions: first, that career choice capability is a problem of individual agency; second, that the dissemination of career information can empower students to act as ‘consumers’ in an unequal job market; third, that agency is simply a question of will; and finally, that school education and career advice – as a means to freedom in the space of career development – is of equal quality, distribution and value to an increasingly diverse range of upper secondary school students. The paper concludes by outlining a conceptual framework capable of informing an empirical research project that aims to test these assumptions by measuring and comparing differences between groups in the range of freedom to achieve and, therefore, to choose.

Who struggles most in making a career choice and why?Findings from a cross-sectional survey of highschool students

This paper reports findings from an empirical study examining the influence of student background and educational experiences on the development of career choice capability. Secondary school students attending years 9-12 (N = 706) in New South Wales (NSW), Australia, were invited to participate in an online survey that sought to examine factors influencing their career choices. The survey included questions relating to student demographics, parental occupation, attitudes to school and to learning, student aspirations, and students’ knowledge of the further education or skills required to achieve their desired goal. We found no significant differences in the proportions of students who were “uncertain” of their future career aspirations with respect to their socio-educational background. There were, however, significantly more students struggling with career decision making from an English-speaking background in comparison to households where children spoke a language other than English. Those students were proportionally present in government and non-government schools and had some behavioural and attitudinal characteristics in common.

Understanding the abnormal brain activity in epilepsy as a potential predictor of the onset of an epileptic seizure

The Brain Research Institute (BRI) uses various types of indirect measurements, including EEG and fMRI, to understand and assess brain activity and function. As well as the recovery of generic information about brain function, research also focuses on the utilisation of such data and understanding to study the initiation, dynamics, spread and suppression of epileptic seizures. To assist with the future focussing of this aspect of their research, the BRI asked the MISG 2010 participants to examine how the available EEG and fMRI data and current knowledge about epilepsy should be analysed and interpreted to yield an enhanced understanding about brain activity occurring before, at commencement of, during, and after a seizure. Though the deliberations of the study group were wide ranging in terms of the related matters considered and discussed, considerable progress was made with the following three aspects. (1) The science behind brain activity investigations depends crucially on the quality of the analysis and interpretation of, as well as the recovery of information from, EEG and fMRI measurements. A number of specific methodologies were discussed and formalised, including independent component analysis, principal component analysis, profile monitoring and change point analysis (hidden Markov modelling, time series analysis, discontinuity identification). (2) Even though EEG measurements accurately and very sensitively record the onset of an epileptic event or seizure, they are, from the perspective of understanding the internal initiation and localisation, of limited utility. They only record neuronal activity in the cortical (surface layer) neurons of the brain, which is a direct reflection of the type of electrical activity they have been designed to record. 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Weak conformance of process models with respect to data objects

Process models specify behavioral aspects by describing ordering constraints between tasks which must be accomplished to achieve envisioned goals. Tasks usually exchange information by means of data objects, i.e., by writing information to and reading information from data objects. A data object can be characterized by its states and allowed state transitions. In this paper, we propose a notion which checks conformance of a process model with respect to data objects that its tasks access. This new notion can be used to tell whether in every execution of a process model each time a task needs to access a data object in a particular state, it is ensured that the data object is in the expected state or can reach the expected state and, hence, the process model can achieve its goals.

Connectivity of workflow nets : the foundations of stepwise verification

Behavioral models capture operational principles of real-world or designed systems. Formally, each behavioral model defines the state space of a system, i.e., its states and the principles of state transitions. Such a model is the basis for analysis of the system’s properties. In practice, state spaces of systems are immense, which results in huge computational complexity for their analysis. Behavioral models are typically described as executable graphs, whose execution semantics encodes a state space. The structure theory of behavioral models studies the relations between the structure of a model and the properties of its state space. In this article, we use the connectivity property of graphs to achieve an efficient and extensive discovery of the compositional structure of behavioral models; behavioral models get stepwise decomposed into components with clear structural characteristics and inter-component relations. At each decomposition step, the discovered compositional structure of a model is used for reasoning on properties of the whole state space of the system. The approach is exemplified by means of a concrete behavioral model and verification criterion. That is, we analyze workflow nets, a well-established tool for modeling behavior of distributed systems, with respect to the soundness property, a basic correctness property of workflow nets. Stepwise verification allows the detection of violations of the soundness property by inspecting small portions of a model, thereby considerably reducing the amount of work to be done to perform soundness checks. Besides formal results, we also report on findings from applying our approach to an industry model collection.

Dark Cartographies

‘Dark Cartographies’ is a slowly evolving meditation upon seasonal change, life after light and the occluding shadows of human influence. Through creating experiences of the many ‘times of a night’ the work allows participants to experience deep engagement with rich spectras of hidden place and sound. By amplifying and shining light upon a myriad of lives lived in blackness, ‘Dark Cartographies’ tempts us to re-understand seasonal change as actively-embodied temporality, inflected by our climate-changing disturbances. ‘Dark Cartographies’ uses custom interactive systems, illusionary techniques and real time spatial audio that draw upon a rich array of media, including seasonal, nocturnal field recordings sourced in the Far North Queensland region and detailed observations of foliage & flowering phases. By drawing inspiration from the subtle transitions between what Europeans named ‘Summer’ and ‘Autumn’, and by including the body and its temporal disturbances within the work, ‘Dark Cartographies’ creates compellingly immersive environments that wrap us in atmospheres beyond sight and hearing. ‘Dark Cartographies’ is a dynamic new installation directed & choreographed by environmental cycles; alluding to a new framework for making works that we call ‘Seasonal’. This powerful, responsive & experiential work draws attention to that which will disappear when biodiverse worlds have descended into an era of permanent darkness – an ‘extinction of human experience’. By tapping into the deeply interlocking seasonal cycles of environments that are themselves intimately linked with social, geographical & political concerns, participating audiences are therefore challenged to see the night, their locality & ecologies in new ways through extending their personal limits of perception, imagery & comprehension.

Cancer : the to and fro of tumour spread

The spread of cells from the primary site of a solid tumour to distant sites remains the major cause of disease and death associated with these cancers. For tumour cells to spread, or metastasize, they must modify their 'anchored' state and detach from their neighbouring cells; migrate through tissues into the blood and lymph systems; survive in these circulation systems; and then leave the vessels at an appropriate site to form another tumour1. Many of these events are favoured by conversions between two cellular states — the epithelial and mesenchymal phenotypes. But the role of these transitions in cancer metastasis is controversial. Writing in Cancer Cell, Tsai et al.2 and Ocaña et al.3 help to clarify this issue...

Progress in epithelial-mesenchymal transition research

The field of research of epithelial-mesenchymal transitions, EMT, and its reverse, mesenchymal-epithelial transitions, MET, has expanded very rapidly indeed from its beginnings, heralded by Professor Betty Hay in the 1970s and 1980s. This expansion has involved the realisation that the EMT was not just an interesting phenomenon of early developmental morphogenetic cell behaviour, but bore remarkable resemblance to clinically crucial pathological events in cancer invasion. Not surprisingly, this discipline soon became numerically dominant in the EMT publication field. Simultaneously, the EMT concept has been extended to normal physiological wound healing. Exploration revealed that these resemblances were more than skin deep: the same sets of growth factors, receptors, transcription factors, epigenetic marks and signalling pathways turned up repeatedly in EMTs and METs in a variety of contexts, both pathological and normal. This molecular genetic research in turn uncovered similarities of the EMT signature to that of fibrosis, a set of diseases which is of enormous clinical importance, rivalling that of cancer. Most recently, and more surprisingly, the EMT signature has shown considerable similarity to that found in stem cell and cancer stem cell biology.

Epithelial-mesenchymal transition

The meeting was designed to explore the intersections of signalling networks regulating and supporting epithelial-mesenchymal (EMT) and mesenchymal-epithelial transitions (MET) in development, fibrosis, and cancer. Particular emphasis was placed on correlations between tissue histology and molecular drivers and markers of EMT and on the therapeutic implications of EMT.

EMT and MET in carcinoma : clinical observations, regulatory pathways and new models

The articles collected here in this special edition Epithelial-Mesenchymal (EMT) and Mesenchymal-Epithelial Transitions (MET) in Cancer provide a snapshot of the very rapidly progressing cinemascope of the involvement of these transitions in carcinoma progression. Pubmed analysis of EMT and cancer shows an exponential increase in the last few years in the number of papers and reviews published under these terms (Fig. 1). The last few years have seen these articles appearing in high calibre journals including Nature, Nature Cell Biology, Cancer Cell, PNAS, JNCI, JCI, and Cell, signaling the acceptance and quality of work in this field.