Outreach and Early Warning Systems (EWS) for the prevention of intensive care admission and death of critically ill adult patients on general hospital wards

BACKGROUND: Despite the fact that outreach and early warning systems (EWS) are an integral part of a hospital wide systems approach to improve the early identification and management of deteriorating patients on general hospital wards, the widespread implementation of these interventions in practice is not based on robust research evidence. OBJECTIVES: The primary objective was to determine the impact of critical care outreach services on hospital mortality rates. Secondary objectives included determining the effect of outreach services on intensive care unit (ICU) admission patterns, length of hospital stay and adverse events. SEARCH STRATEGY: The review authors searched the following electronic databases: EPOC Specialised Register, The Cochrane Central Register of Controlled Trials (CENTRAL) and other Cochrane databases (all on The Cochrane Library 2006, Issue 3), MEDLINE (1996-June week 3 2006), EMBASE (1974-week 26 2006), CINAHL (1982-July week 5 2006), First Search (1992-2005) and CAB Health (1990-July 2006); also reference lists of relevant articles, conference abstracts, and made contact with experts and critical care organisations for further information. SELECTION CRITERIA: Randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series designs (ITS) which measured hospital mortality, unanticipated ICU admissions, ICU readmissions, length of hospital stay and adverse events following implementation of outreach and EWS in a general hospital ward to identify deteriorating adult patients versus general hospital ward setting without outreach and EWS were included in the review. DATA COLLECTION AND ANALYSIS: Three review authors independently extracted data and two review authors assessed the methodological quality of the included studies. Meta-analysis was not possible due to heterogeneity. Summary statistics and descriptive summaries of primary and secondary outcomes are presented for each study. MAIN RESULTS: Two cluster-randomised control trials were included: one randomised at hospital level (23 hospitals in Australia) and one at ward level (16 wards in the UK). The primary outcome in the Australian trial (a composite score comprising incidence of unexpected cardiac arrests, unexpected deaths and unplanned ICU admissions) showed no statistical significant difference between control and medical emergency team (MET) hospitals (adjusted P value 0.640; adjusted odds ratio (OR) 0.98; 95% confidence interval (CI) 0.83 to 1.16). The UK-based trial found that outreach reduced in-hospital mortality (adjusted OR 0.52; 95% CI 0.32 to 0.85) compared with the control group. AUTHORS' CONCLUSIONS: The evidence from this review highlights the diversity and poor methodological quality of most studies investigating outreach. The results of the two included studies showed either no evidence of the effectiveness of outreach or a reduction in overall mortality in patients receiving outreach. The lack of evidence on outreach requires further multi-site RCT's to determine potential effectiveness.

Influence of preparation conditions on the characteristics of activated carbons produced in laboratory and pilot scale systems

The central theme of this investigation is to evaluate the feasibility of using bituminous coal as a precursor material for the production of chars and activated carbons using physical and chemical activation processes. The chemical activation process was accomplished by impregnating the raw materials with different dehydrating agents in different ratios and concentrations, prior to heat treatment (ZnCl2, KCl, KOH, NaOH and Fe2(SO4)3·xH2O). Steam activation of the precursor material was adopted for the preparation of activated carbon using physical activation technology. Different types of bituminous coal; namely, contaminated Columbian (contaminated with pet. coke), pure Columbian, Venezuelan and New Zealand bituminous coal were used in the production processes. BET surface area, micropore area, pore size distribution and total pore volume of the chars and activated carbons were determined from N2 adsorption/desorption isotherm, measured at 77 K. Charring conditions, charring temperature of 800 °C and charring time of 4 h, proved to be the optimum conditions for preparing chars. Contaminated Columbian were found to be the best precursor material for the production of char with reasonable physical characteristics (surface area = 138.1 m2 g-1 and total pore volume of 8.656 × 10-0.2 cm3 g-1). An improvement in the physical characteristics of the activated carbons was obtained upon the treatment of coal with dehydrating agents. Contaminated Columbian treated with 10 wt% ZnCl2 displayed the highest surface area and total pore volume (surface area = 231.5 m2 g-1 and total pore volume = 0.1227 cm3 g-1) with well-developed microporisity (micropore area = 92.3 m2 g-1). Venezuelan bituminous coal using the steam activation process was successful in producing activated carbon with superior physical characteristics (surface area = 863.50 m2 g-1, total pore volume = 0.469 cm3 g-1 and micropore surface area = 783.58 m2 g-1).

Exploring the adoption and implementation of discrete and integrated IT systems: A Framework for analysis

Despite the substantial organisational benefits of integrated IT, the implementation of such systems – and particularly Enterprise Resource Planning (ERP) systems – has tended to be problematic, stimulating an extensive body of research into ERP implementation. This research has remained largely separate from the main IT implementation literature. At the same time, studies of IT implementation have generally adopted either a factor or process approach; both have major limitations. To address these imitations, factor and process perspectives are combined here in a unique model of IT implementation. We argue that • the organisational factors which determine successful implementation differ for integrated and traditional, discrete IT • failure to manage these differences is a major source of integrated IT failure. The factor/process model is used as a framework for proposing differences between discrete and integrated IT.

FAULT-TOLERANT ALGORITHM FOR HIGH-AVAILABILITY AND WAFER SCALE SYSTEMS.

In this paper, the authors have presented one approach to configuring a Wafer-Scale Integration Chip. The approach described is called the 'WINNER', in which bus channels and an external controller for configuring the working processors are not required. In addition, the technique is applicable to high availability systems constructed using conventional methods. The technique can also be extended to arrays of arbitrary size and with any degree of fault tolerance simply by using an appropriate number of cells.

The two-way relationship between the Balanced Scorecard and Management Control Systems in organizations:Lessons from a Case Study

This paper reports a case study conducted in Quinta da Aveleda, one of
the three largest Portuguese wine companies. Our aim was to explore the
relationship established between a newly implemented Balanced Scorecard
(BSC) and the elements of the Management Control System (MCS) in the
organization. Thus, two specific objectives were pursued. Firstly, to identify
the influences (barriers, opportunities) of the existing MCS on the implementation
of the BSC. Secondly, to identify the impacts the BSC implementation
was able to exert on the configuration of the organization’s MCS.
We found that the budgeting process, the planning system, the information
infrastructure, and the organizational structure and culture were the elements
of the previous MCS that influenced the BSC implementation process.
Eventually, the BSC implementation led to important changes in the budgeting,
planning, reporting systems and processes. In order to explain these
findings, we briefly explored the main issues and factors accounting for the
scope and nature of the BSC’s impacts on Quinta da Aveleda. These issues
and factors were the mobilized organizational resources, the implementation
approach, the communication, and the organizational support.

Distillable entanglement and area laws in spin and harmonic-oscillator systems

We address the presence of nondistillable (bound) entanglement in natural many-body systems. In particular, we consider standard harmonic and spin-1/2 chains, at thermal equilibrium and characterized by few interaction parameters. The existence of bound entanglement is addressed by calculating explicitly the negativity of entanglement for different partitions. This allows us to individuate a range of temperatures for which no entanglement can be distilled by means of local operations, despite the system being globally entangled. We discuss how the appearance of bound entanglement can be linked to entanglement-area laws, typical of these systems. Various types of interactions are explored, showing that the presence of bound entanglement is an intrinsic feature of these systems. In the harmonic case, we analytically prove that thermal bound entanglement persists for systems composed by an arbitrary number of particles. Our results strongly suggest the existence of bound entangled states in the macroscopic limit also for spin-1/2 systems.

Risk and Reward: Safer systems of work practice.

To develop and implement a risk assessment process for all unlicenced medicinal products in use within the Belfast City Hospital.
Over half 65% of the unlicenced medicinal products currently in use were rated low or minor risk and therefore required no recording upon supply.
This has greatly improved the way unlicensed medicines are prescribed, procured, supplied and administered within the Belfast City Hospital.

Logic and Memory Design Based on Unequal Error Protection for Voltage-scalable, Robust and Adaptive DSP Systems

In this paper, we propose a system level design approach considering voltage over-scaling (VOS) that achieves error resiliency using unequal error protection of different computation elements, while incurring minor quality degradation. Depending on user specifications and severity of process variations/channel noise, the degree of VOS in each block of the system is adaptively tuned to ensure minimum system power while providing "just-the-right" amount of quality and robustness. This is achieved, by taking into consideration block level interactions and ensuring that under any change of operating conditions, only the "less-crucial" computations, that contribute less to block/system output quality, are affected. The proposed approach applies unequal error protection to various blocks of a system-logic and memory-and spans multiple layers of design hierarchy-algorithm, architecture and circuit. The design methodology when applied to a multimedia subsystem shows large power benefits ( up to 69% improvement in power consumption) at reasonable image quality while tolerating errors introduced due to VOS, process variations, and channel noise.