Development of process control methodology for tracking the quality and safety of pain, agitation and sedation management in critical care units

Objective: To develop sedation, pain, and agitation quality measures using process control methodology and evaluate their properties in clinical practice. Design: A Sedation Quality Assessment Tool was developed and validated to capture data for 12-hour periods of nursing care. Domains included pain/discomfort and sedation-agitation behaviors; sedative, analgesic, and neuromuscular blocking drug administration; ventilation status; and conditions potentially justifying deep sedation. Predefined sedation-related adverse events were recorded daily. Using an iterative process, algorithms were developed to describe the proportion of care periods with poor limb relaxation, poor ventilator synchronization, unnecessary deep sedation, agitation, and an overall optimum sedation metric. Proportion charts described processes over time (2 monthly intervals) for each ICU. The numbers of patients treated between sedation-related adverse events were described with G charts. Automated algorithms generated charts for 12 months of sequential data. Mean values for each process were calculated, and variation within and between ICUs explored qualitatively. Setting: Eight Scottish ICUs over a 12-month period. Patients: Mechanically ventilated patients. Interventions: None. Measurements and Main Results: The Sedation Quality Assessment Tool agitation-sedation domains correlated with the Richmond Sedation Agitation Scale score (Spearman [rho] = 0.75) and were reliable in clinician-clinician (weighted kappa; [kappa] = 0.66) and clinician-researcher ([kappa] = 0.82) comparisons. The limb movement domain had fair correlation with Behavioral Pain Scale ([rho] = 0.24) and was reliable in clinician-clinician ([kappa] = 0.58) and clinician-researcher ([kappa] = 0.45) comparisons. Ventilator synchronization correlated with Behavioral Pain Scale ([rho] = 0.54), and reliability in clinician-clinician ([kappa] = 0.29) and clinician-researcher ([kappa] = 0.42) comparisons was fair-moderate. Eight hundred twenty-five patients were enrolled (range, 59-235 across ICUs), providing 12,385 care periods for evaluation (range 655-3,481 across ICUs). The mean proportion of care periods with each quality metric varied between ICUs: excessive sedation 12-38%; agitation 4-17%; poor relaxation 13-21%; poor ventilator synchronization 8-17%; and overall optimum sedation 45-70%. Mean adverse event intervals ranged from 1.5 to 10.3 patients treated. The quality measures appeared relatively stable during the observation period. Conclusions: Process control methodology can be used to simultaneously monitor multiple aspects of pain-sedation-agitation management within ICUs. Variation within and between ICUs could be used as triggers to explore practice variation, improve quality, and monitor this over time

Exploring alternatives for milk quality improvement and more efficient dairy production in a smallholder farming context – case study: Mantaro Valley (Peru)

Consumer demand is revolutionizing the way products are being produced, distributed and marketed. In relation to the dairy sector in developing countries, aspects of milk quality are receiving more attention from both society and the government. However, milk quality management needs to be better addressed in dairy production systems to guarantee the access of stakeholders, mainly small-holders, into dairy markets. The present study is focused on an analysis of the interaction of the upstream part of the dairy supply chain (farmers and dairies) in the Mantaro Valley (Peruvian central Andes), in order to understand possible constraints both stakeholders face implementing milk quality controls and practices; and evaluate “ex-ante” how different strategies suggested to improve milk quality could affect farmers and processors’ profits. The analysis is based on three complementary field studies conducted between 2012 and 2013. Our work has shown that the presence of a dual supply chain combining both formal and informal markets has a direct impact on dairy production at the technical and organizational levels, affecting small formal dairy processors’ possibilities to implement contracts, including agreements on milk quality standards. The analysis of milk quality management from farms to dairy plants highlighted the poor hygiene in the study area, even when average values of milk composition were usually high. Some husbandry practices evaluated at farm level demonstrated cost effectiveness and a big impact on hygienic quality; however, regular application of these practices was limited, since small-scale farmers do not receive a bonus for producing hygienic milk. On the basis of these two results, we co-designed with formal small-scale dairy processors a simulation tool to show prospective scenarios, in which they could select their best product portfolio but also design milk payment systems to reward farmers’ with high milk quality performances. This type of approach allowed dairy processors to realize the importance of including milk quality management in their collection and manufacturing processes, especially in a context of high competition for milk supply. We concluded that the improvement of milk quality in a smallholder farming context requires a more coordinated effort among stakeholders. Successful implementation of strategies will depend on the willingness of small-scale dairy processors to reward farmers producing high milk quality; but also on the support from the State to provide incentives to the stakeholders in the formal sector.

Enteral feeding methods for nutritional management in patients with head and neck cancers being treated with radiotherapy and/or chemotherapy

Background: This is an update of a Cochrane review first published in The Cochrane Library in Issue 3, 2010.
For many patients with head and neck cancer, oral nutrition will not provide adequate nourishment during treatment with radiotherapy or chemoradiotherapy due to the acute toxicity of treatment, obstruction caused by the tumour, or both. The optimal method of enteral feeding for this patient group has yet to be established.

Objectives: To compare the effectiveness of different enteral feeding methods used in the nutritional management of patients with head and neck cancer receiving radiotherapy or chemoradiotherapy using the clinical outcomes, nutritional status, quality of life and rates of complications.

Search methods: Our extensive search included the Cochrane ENT Group Trials Register, CENTRAL, PubMed, EMBASE, CINAHL, AMED and ISI Web of Science. The date of the most recent search was 13 February 2012.

Selection criteria:Randomised controlled trials comparing one method of enteral feeding with another, e.g. nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) feeding, for adult patients with a diagnosis of head and neck cancer receiving radiotherapy and/or chemoradiotherapy.

Data collection and analysis:Two authors independently assessed trial quality and extracted data using standardised forms. We contacted study authors for additional information.

Main results: One randomised controlled trial met the criteria for inclusion in this review. No further studies were identified when we updated the searches in 2012.
Patients diagnosed with head and neck cancer, being treated with chemoradiotherapy, were randomised to PEG or NG feeding. In total only 33 patients were eligible for analysis as the trial was terminated early due to poor accrual. A high degree of bias was identified in the study.
Weight loss was greater for the NG group at six weeks post-treatment than for the PEG group (P = 0.001). At six months post-treatment, however, there was no significant difference in weight loss between the two groups. Anthropometric measurements recorded six weeks post-treatment demonstrated lower triceps skin fold thickness for the NG group compared to the PEG group (P = 0.03). No statistically significant difference was found between the two different enteral feeding techniques in relation to complication rates or patient satisfaction. The duration of PEG feeding was significantly longer than for the NG group (P = 0.0006). In addition, the study calculated the cost of PEG feeding to be 10 times greater than that of NG, though this was not found to be significant. There was no difference in the treatment received by the two groups. However, four PEG fed patients and two NG fed patients required unscheduled treatment breaks of a median of two and six days respectively.
We identified no studies of enteral feeding involving any form of radiologically inserted gastrostomy (RIG) feeding or comparing prophylactic PEG versus PEG for inclusion in the review.

Authors' conclusions: There is not sufficient evidence to determine the optimal method of enteral feeding for patients with head and neck cancer receiving radiotherapy and/or chemoradiotherapy. Further trials of the two methods of enteral feeding, incorporating larger sample sizes, are required.

Emergency Management in Developed Countries: An Investigation of Hazard Risk, Vulnerability and Government Response in the UK and USA

During the summer of 2007 the United Kingdom experienced some of the worst flooding in its history, with the city of Hull amongst the worst affected. Meanwhile, the city of New Orleans, USA was subject to severe flooding in August 2005 as a result of Hurricane Katrina. The study has found that both the UK and US government disaster management programmes were ill prepared for these flood events. Many parallel issues have been discovered and discussed. The conditions of vulnerability that are evident in developing countries are not widely present in the UK or US but this must not be allowed to lead to complacency and lack of preparation and awareness. The cost in terms of mortality is relatively low compared to similar events in developing countries; however, the economic implications are considerable and must be addressed.

The role of operations management in public sector policy and practice alignment: a local government analysis

In responding to the demand for change and improvement, local government has applied a plethora of operations management-based methods, tools and techniques. This article explores how these methods, specifically in the form of performance management models, are used to improve alignment between central government policy and local government practice, an area which has thus far been neglected in the literature. Using multiple case studies from Environmental Waste Management Services, this research reports that models derived in the private sector are often directly ‘implanted’ into the public sector. This has challenged the efficacy of all performance management models. However, those organisations which used models most effectively did so by embedding (contextualisation) and extending (reconceptualisation) them beyond their original scope. Moreover, success with these models created a cumulative effect whereby other operations management approaches were probed, adapted and used.

Quality Management and Managerialism in Healthcare:: A Critical Historical Survey

Quality Management and Managerialism in Healthcare creates a comprehensive and systematic international survey of various perspectives on healthcare quality management together with some of their most pertinent critiques. Chapter one starts with a general discussion of the factors that drove the introduction of management paradigms into public sector and health management contexts in the mid to late 1980s. Chapter two explores the rise of risk awareness in medicine; which, prior to the 1980s, stood largely in isolation to the implementation of managerial performance targets. Chapter three investigates the widespread adoption of performance management and clinical governance frameworks during the 1980s and 1990s. This is followed by Chapters four and five which examine systems based models of patient safety and the evidence-based medicine movement as exemplars of managerial perspectives on healthcare quality. Chapter six discusses potential future avenues for the development of alternative perspectives on quality of care which emphasise workforce involvement. The book concludes by reviewing the factors which have underpinned the managerialist trajectory of healthcare management over the past decades and explores the potential impact of nascent technologies such as 'connected health' and 'telehealth' on future developments.

Beach quality assessment and management in the Sotavento (Eastern) Algarve, Portugal

The purpose of this study on beach quality assessment and management was to evaluate the quality of five beaches in the Algarve Sotavento region of Portugal and to identify beach users’ preferences and priorities regarding their visit to a beach. The Algarve is one of the country’s most internationally known regions and it is generally perceived as a major tourist destination. Because of the increasing level of tourists, there is a specific need to address beach quality, as overcrowding can result in excessive litter, reduce water quality and consequently reduce the socio-economic value of the area. The main methodology for the evaluation of the beach quality in this pilot project was the Bathing Area Registration and Evaluation framework (BARE), which recognizes five beach types (rural, remote, resort, urban and village) through five main priority issues of concern to beach users (water quality, scenery, litter, safety, facilities) and evaluates the beach quality, ranging from one (low) to five (high) stars. After overall bathing area classification, Quarteira-Vilamoura, Ilha do Farol, Ilha Deserta and Ilha da Armona received three-star rating and Quinta do Lago site obtained a one-star rating. The quantitative research data on beach users’ preferences and priorities was obtained through administration of 50 questionnaires per beach and showed that beach users at all sites expressed the need for improved cleanliness, safety and facilities on the beach. The BARE framework, together with the questionnaire surveys, allowed the identification of management priorities required to improve the quality of individual beaches and therefore increase income from tourism.

Freight Quality Partnerships in the UK: an analysis of their work and achievements

The report contains details of the number and type of Freight Quality Partnerships (FQPs) that exist in the UK, their structure, their aims and objectives, their activities and outputs, their challenges, successes and failings, and the extent to which they work with and learn from each other. Through survey work, the study also sought the views of those directly involved in the operation and management of FQPs about the FQP concept, whether they have improved partnership working between the public and private sector, the value for money that they provide, and actions that central government and other organisations could take to improve their success and effectiveness.

Integrating Financial Perspective to Quality Orientated Management System. Case: ALSTOM Finland Oy

Tutkimuksen päätavoitteena on tutkia taloudellisen näkökulman integroimista laatuajatteluun pohjautuvaan johtamisjärjestelmään esimerkkiyrityksessä. Johtamisjärjestelmän tulee tuottaa tietoa johdon strategiselle päätöksenteolle ja lisäksi täyttää laatujärjestelmän (ISO 9001:2000) asettamat vaatimukset. Tutkimuksen kohteena oleva työkalu on balanced scorecard (tasapainotettu tuloskortti). Työn tarkoituksena on ehdottaa balanced scorecard- talouden tunnuslukuja esimerkkiyritykselle. Tutkimuksen tavoitteisiin päästään empiiristä tutkimusta varten tehdyn teoreettisen viitekehyksen avulla. Empiiristä tutkimustietoa kerätään osallistuvan havainnoinnin, haastattelujen ja keskustelujen avulla. Tutkimusmenetelmänä on laadullinen case -tutkimus. Balanced scorecardin eri näkökulmille ehdotettiin tunnuslukuja empiirisen tutkimuksen pohjalta. Lisäksi talouden näkökulmaa tutkittiin tarkemmin. Tutkimuksen johtopäätöksenä esitettiin, että taloudelliset tunnusluvut mittaavat ensisijaisesti strategiaa eivätkä laatua. Lisäksi huomioitiin, että tuloskorttien tulisi olla koekäytössä ennen bonuspalkkauksen ja balanced scorecardin yhdistämistä.

Development and Integration of Biocontrol Products in Branched Broomrape (Phelipanche ramosa) management in Tomato

Parasitic weeds of the genera Striga, Orobanche, and Phelipanche pose a severe problem for agriculture because they are difficult to control and are highly destructive to several crops. The present work was carried out during the period October, 2009 to February, 2012 to evaluate the potential of arbuscular mycorrhizal fungi (AMF) to suppress P. ramosa on tomatoes and to investigate the effects of air-dried powder and aqueous extracts from Euphorbia hirta on germination and haustorium initiation in Phelipanche ramosa. The work was divided into three parts: a survey of the indigenous mycorrhizal flora in Sudan, second, laboratory and greenhouse experiments (conducted in Germany and Sudan) to construct a base for the third part, which was a field trial in Sudan. A survey was performed in 2009 in the White Nile state, Sudan to assess AMF spore densities and root colonization in nine fields planted with 13 different important agricultural crops. In addition, an attempt was made to study the relationship between soil physico-chemical properties and AMF spore density, colonization rate, species richness and other diversity indices. The mean percentage of AMF colonization was 34%, ranging from 19-50%. The spore densities (expressed as per 100 g dry soil) retrieved from the rhizosphere of different crops were relatively high, varying from 344 to 1222 with a mean of 798. There was no correlation between spore densities in soil and root colonization percentage. A total of 45 morphologically classifiable species representing ten genera of AMF were detected with no correlation between the number of species found in a soil sample and the spore density. The most abundant genus was Glomus (20 species). The AMF diversity expressed by the Shannon–Weaver index was highest in sorghum (H\= 2.27) and Jews mallow (H\= 2.13) and lowest in alfalfa (H\= 1.4). With respect to crop species, the genera Glomus and Entrophospora were encountered in almost all crops, except for Entrophospora in alfalfa. Kuklospora was found only in sugarcane and sorghum. The genus Ambispora was recovered only in mint and okra, while mint and onion were the only species on which no Acaulospora was found. The hierarchical cluster analysis based on the similarity among AMF communities with respect to crop species overall showed that species compositions were relatively similar with the highest dissimilarity of about 25% separating three of the mango samples and the four sorghum samples from all other samples. Laboratory experiments studied the influence of root and stem exudates of three tomato varieties infected by three different Glomus species on germination of P. ramosa. Root exudates were collected 21or 42 days after transplanting (DAT) and stem exudates 42 DAT and tested for their effects on germination of P. ramosa seeds in vitro. The tomato varieties studied did not have an effect on either mycorrhizal colonization or Phelipanche germination. Germination in response to exudates from 42 day old mycorrhizal plants was significantly reduced in comparison to non-mycorrhizal controls. Germination of P. ramosa in response to root exudates from 21 day old plants was consistently higher than for 42 day-old plants (F=121.6; P<.0001). Stem diffusates from non-mycorrhizal plants invariably elicited higher germination than diffusates from the corresponding mycorrhizal ones and differences were mostly statistically significant. A series of laboratory experiments was undertaken to investigate the effects of aqueous extracts from Euphorbia hirta on germination, radicle elongation, and haustorium initiation in P. ramosa. P. ramosa seeds conditioned in water and subsequently treated with diluted E. hirta extract (10-25% v/v) displayed considerable germination (47-62%). Increasing extract concentration to 50% or more reduced germination in response to the synthetic germination stimulants GR24 and Nijmegen-1 in a concentration dependent manner. P. ramosa germlings treated with diluted Euphorbia extract (10-75 % v/v) displayed haustorium initiation comparable to 2, 5-Dimethoxy-p-benzoquinon (DMBQ) at 20 µM. Euphorbia extract applied during conditioning reduced haustorium initiation in a concentration dependent manner. E. hirta extract or air-dried powder, applied to soil, induced considerable P. ramosa germination. Pot experiments were undertaken in a glasshouse at the University of Kassel, Germany, to investigate the effects of P. ramosa seed bank on tomato growth parameters. Different Phelipanche seed banks were established by mixing the parasite seeds (0 - 32 mg) with the potting medium in each pot. P. ramosa reduced all tomato growth parameters measured and the reduction progressively increased with seed bank. Root and total dry matter accumulation per tomato plant were most affected. P. ramosa emergence, number of tubercles, and tubercle dry weight increased with the seed bank and were, invariably, maximal with the highest seed bank. Another objective was to determine if different AM fungi differ in their effects on the colonization of tomatoes with P. ramosa and the performance of P. ramosa after colonization. Three AMF species viz. GIomus intraradices, Glomus mosseae and Glomus Sprint® were used in this study. For the infection, P. ramosa seeds (8 mg) were mixed with the top 5 cm soil in each pot. No mycorrhizal colonization was detected in un-inoculated control plants. P. ramosa infested, mycorrhiza inoculated tomato plants had significantly lower AMF colonization compared to plants not infested with P. ramosa. Inoculation with G. intraradices, G. mosseae and Glomus Sprint® reduced the number of emerged P. ramosa plants by 29.3, 45.3 and 62.7% and the number of tubercles by 22.2, 42 and 56.8%, respectively. Mycorrhizal root colonization was positively correlated with number of branches and total dry matter of tomatoes. Field experiments on tomato undertaken in 2010/12 were only partially successful because of insect infestations which resulted in the complete destruction of the second run of the experiment. The effects of the inoculation with AMF, the addition of 10 t ha-1 filter mud (FM), an organic residues from sugar processing and 36 or 72 kg N ha-1 on the infestation of tomatoes with P. ramosa were assessed. In un-inoculated control plants, AMF colonization ranged between 13.4 to 22.1% with no significant differences among FM and N treatments. Adding AMF or FM resulted in a significant increase of branching in the tomato plants with no additive effects. Dry weights were slightly increased through FM application when no N was applied and significantly at 36 kg N ha-1. There was no effect of FM on the time until the first Phelipanche emerged while AMF and N application interacted. Especially AMF inoculation resulted in a tendency to delayed P. ramosa emergence. The marketable yield was extremely low due to the strong fruit infestation with insects mainly whitefly Bemisia tabaci and tomato leaf miner (Tuta absoluta). Tomatoes inoculated with varied mycorrhiza species displayed different response to the insect infestation, as G. intraradices significantly reduced the infestation, while G. mosseae elicited higher insect infestation. The results of the present thesis indicate that there may be a potential of developing management strategies for P. ramosa targeting the pre-attachment stage namely germination and haustorial initiation using plant extracts. However, ways of practical use need to be developed. If such treatments can be combined with AMF inoculation also needs to be investigated. Overall, it will require a systematic approach to develop management tools that are easily applicable and affordable to Sudanese farmers. It is well-known that proper agronomical practices such as the design of an optimum crop rotation in cropping systems, reduced tillage, promotion of cover crops, the introduction of multi-microbial inoculants, and maintenance of proper phosphorus levels are advantageous if the mycorrhiza protection method is exploited against Phelipanche ramosa infestation. Without the knowledge about the biology of the parasitic weeds by the farmers and basic preventive measures such as hygiene and seed quality control no control strategy will be successful, however.

Visual management of sags and incidents gathered in distribution substations for power quality management

Monitor a distribution network implies working with a huge amount of data coining from the different elements that interact in the network. This paper presents a visualization tool that simplifies the task of searching the database for useful information applicable to fault management or preventive maintenance of the network

Implementación del Total Productive Management (TPM) como tecnología de gestión para el desarrollo de los procesos de MAQUIAVICOLA LTDA.

En el desarrollo de este trabajo de grado se describe la filosofía de calidad Total Productive Managment (TPM) y se desarrolla el plan de implementación de esta en una empresa del sector avícola colombiano conocida como MAQUIAVICOLA LTDA. Esta implementación tiene por objetivo optimizar la ejecución de los procesos productivos que se desarrollan dentro de la empresa con el fin de incrementar su productividad. A partir de la descripción de los conceptos y herramientas que contempla esta filosofía, se diseña un plan de implementación que va a permitir aplicar este modelo al desarrollo de los procesos diarios de la empresa, contribuyendo a la mejora de indicadores de gestión.