Clinical interventions, implementation interventions, and the potential greyness in between - a discussion paper

Background: There is increasing awareness that regardless of the proven value of clinical interventions, the use of effective strategies to implement such interventions into clinical practice is necessary to ensure that patients receive the benefits. However, there is often confusion between what is the clinical intervention and what is the implementation intervention. This may be caused by a lack of conceptual clarity between 'intervention' and 'implementation', yet at other times by ambiguity in application. We suggest that both the scientific and the clinical communities would benefit from greater clarity; therefore, in this paper, we address the concepts of intervention and implementation, primarily as in clinical interventions and implementation interventions, and explore the grey area in between. Discussion: To begin, we consider the similarities, differences and potential greyness between clinical interventions and implementation interventions through an overview of concepts. This is illustrated with reference to two examples of clinical interventions and implementation intervention studies, including the potential ambiguity in between. We then discuss strategies to explore the hybridity of clinical-implementation intervention studies, including the role of theories, frameworks, models, and reporting guidelines that can be applied to help clarify the clinical and implementation intervention, respectively. Conclusion: Semantics provide opportunities for improved precision in depicting what is 'intervention' and what is 'implementation' in health care research. Further, attention to study design, the use of theory, and adoption of reporting guidelines can assist in distinguishing between the clinical intervention and the implementation intervention. However, certain aspects may remain unclear in analyses of hybrid studies of clinical and implementation interventions. Recognizing this potential greyness can inform further discourse.

Cooperative memory and database transactions

Dissertação apresentada na Faculdade de Ciências e Tecnologia da Universidade Nova de Lisboa para a obtenção do Grau de Mestre em Engenharia Informática

Desenvolupament de sistemes integrats de veuip i missatgeria instantània

Els objectius d'aquest projecte són, la implementació de sistemes oberts que permetin la comunicació VEUIP i MI

Implantació d'una solució SIG per al'ajuda a la presa de decisions perl'explotació de recursos del subsòl

Aquest projecte té com a objectiu la implementació d¿un Sistema d¿InformacióGeogràfic (SIG) que permeti ajudar en la presa de decisions per l¿explotació derecursos del subsòl.

Generació de codi amb WebRatio

L'objectiu d'aquest PFC és la implementació d'una eina que s'encarregui de transformar un model de dades en un model de navegació complet i correcte. Per fer-ho, el programa WebRatio suporta completament el llenguatge WebML i s'utilitzarà com a dissenyador dels models de dades i també com a eina per comprovar els models de navegació generats.

Xifratge d'arxius

L'objectiu d'aquest treball és la implementació d'una utilitat per xifrar fitxers amb claus basades en contrasenyes. En concret, l'usuari introduirà una contrasenya que li permetrà xifrar i, posteriorment desxifrar, un determinat arxiu o carpeta. La clau per xifrar i desxifrar es basa en la contrasenya introduïda de forma que el sistema sigui prou segur.

Protecció del copyright

L'objectiu d'aquest TFC és implementar un sistema senzill de protecció del copyright per a imatges de format BMP mitjançant un esquema de marcatge basat en codis duals de Hamming, que permeten recuperar la marca quan la imatge marcada ha estat sotmesa a certs tipus de processament digital i també en el cas de confabulació de dos compradors.

Osaamisen johtaminen ja sen toteutuminen Case elintarvikeyritys

Tämän tutkimuksen tavoitteena oli ymmärtää, miten kohdeyrityksen työntekijöiden osaamisen johtaminen toteutuu. Tutkimus oli luonteeltaan kvalitatiivinen, ja sen empiirinen aineisto koostui kohdeyrityksen kahdeksan esimiehen teemahaastattelusta. Tulosten perusteella voidaan vahvistaa toiminnon osaamisen johtamisen ja osaamisen tunnistamisen toteutuneen toisen kehitysvaiheen mukaisesti. Esimiehet olivat ymmärtäneet työntekijöiden osaamisen merkityksen liiketoimintaa edistävänä tekijänä. Tärkeäksi kehittämisen kohteeksi nousi nykyinen kehityskeskustelukäytäntö, joka tulee muuttaa toiminnon liiketoimintaa ja työntekijöiden osaamista tukevampaan muotoon. Lisäksi esimiehillä oli työntekijöiden osaamisen johtamista varten käytössään erilaisia toimintatapoja ja työvälineitä, joita tulee jatkossa kehittää ja yhtenäistää.

E-Business Intreoperability Frameworks for SMEs

Current e-business standards have been developed and used by large organizations to reduce clerical costs in business transactions by increased automation and higher level of business-to-business integration. Small and medium enterprises (SME's), however, cannot easily adopt these standards due to the SME's lacking the technical expertise and resources for implementing them. Still, large organizations increasingly require their business partners, most of which are SME's, to be able to interoperate by their chosen e-business standards. The research question for the study was, first, which of the existing e-business technologies are most SME-adoptable, and, second, how could those e-business technologies be made easier for SME's to implement. The study was conducted as a literature study that evaluated the available e-business frameworks and SME-oriented e-business architectures based on the implementation complexity and costs incurred for the SME adopter. The study found that only few e-business solutions are SMEadoptable. The technological approaches used in the solutions need to be improved on a number of areas, the most important of which is implementation complexity. The study revealed that this also applies to the special, SME-oriented e-business architectures, which are also still too difficult for SME's to implement. Based on these findings, a high-level e-business interoperability framework concept was proposed as the basis for future research to overcome the found implementation complexities for SME's.

Prosessihöyryn tuotannon kustannusoptimointi

Tässä työssä on tutkittu prosessihöyryn tuotantokustannusten optimointia Neste Oil Oy:n Naantalin jalostamolla. Työssä on keskitytty ennen kaikkea prosessi-höyryn tuotantoon öljynjalostamolla. Tavoitteena oli luoda yksinkertainen työkalu, jonka avulla voidaan vertailla höyryntuotantokustannuksia jalostamon tuotan-toyksiköissä. Samalla oli tarkoituksena kartoittaa höyryn tuotantomahdollisuudet yksiköissä. Työn tuloksena tehty Excel-pohjainen laskentataulukko on esitelty tässä työssä. Ohjelman tarkkuutta on mahdollista parantaa prosessikoeajojen avul-la. Jo nykyisellä laskentatarkkuudella ohjelma täyttää kuitenkin asetetut tavoitteet eli antaa mahdollisuuden vertailla helposti ja havainnollisesti tuotantokustannuksia yksiköiden välillä. Oman höyryntuotannon lisäksi Naantalin jalostamo ostaa höyryä viereiseltä Fortumin Naantalin voimalaitokselta. Ostohöyryn hinta on las-kettu työkalussa mukaan vertailuun. Työn perusteella ostohöyry on Naantalin ja-lostamon tapauksessa selkeästi omatuotantoa edullisempi vaihtoehto. Ero kustan-nuksissa syntyy käytettävästä polttoaineesta, joka jalostamon tapauksessa on ja-lostamo- eli polttokaasu. Nykyisen tasoisella raakaöljyn hinnalla tilanne säilynee tällaisena tulevaisuudessakin. Jalostamolta löytyi myös kohteita, joissa energiatehokkuutta on mahdollista kehit-tää nykyisen höyryverkon ulkopuolella. Esimerkkeinä tällaisista kohteista tässä työssä on tarkasteltu toisen jätelämpökattilan rakentamista nykyisen toiminnassa olevan rinnalle, sekä höyryturbiinien asentamista paineenalennuslinjoihin. Näistä hankkeista jätelämpökattila osoittautui erittäin suositeltavaksi investoinniksi.

Practice and perception--a nationwide survey of therapy habits in sepsis

OBJECTIVE: To simultaneously determine perceived vs. practiced adherence to recommended interventions for the treatment of severe sepsis or septic shock. DESIGN: One-day cross-sectional survey. SETTING: Representative sample of German intensive care units stratified by hospital size. PATIENTS: Adult patients with severe sepsis or septic shock. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Practice recommendations were selected by German Sepsis Competence Network (SepNet) investigators. External intensivists visited intensive care units randomly chosen and asked the responsible intensive care unit director how often these recommendations were used. Responses "always" and "frequently" were combined to depict perceived adherence. Thereafter patient files were audited. Three hundred sixty-six patients on 214 intensive care units fulfilled the criteria and received full support. One hundred fifty-two patients had acute lung injury or acute respiratory distress syndrome. Low-tidal volume ventilation < or = 6 mL/kg/predicted body weight was documented in 2.6% of these patients. A total of 17.1% patients had tidal volume between 6 and 8 mL/kg predicted body weight and 80.3% > 8 mL/kg predicted body weight. Mean tidal volume was 10.0 +/- 2.4 mL/kg predicted body weight. Perceived adherence to low-tidal volume ventilation was 79.9%. Euglycemia (4.4-6.1 mmol/L) was documented in 6.2% of 355 patients. A total of 33.8% of patients had blood glucose levels < or = 8.3 mmol/L and 66.2% were hyperglycemic (blood glucose > 8.3 mmol/L). Among 207 patients receiving insulin therapy, 1.9% were euglycemic, 20.8% had blood glucose levels < or = 8.3 mmol/L, and 1.0% were hypoglycemic. Overall, mean maximal glucose level was 10.0 +/- 3.6 mmol/L. Perceived adherence to strict glycemic control was 65.9%. Although perceived adherence to recommendations was higher in academic and larger hospitals, actual practice was not significantly influenced by hospital size or university affiliation. CONCLUSIONS: This representative survey shows that current therapy of severe sepsis in German intensive care units complies poorly with practice recommendations. Intensive care unit directors perceive adherence to be higher than it actually is. Implementation strategies involving all intensive care unit staff are needed to overcome this gap between current evidence-based knowledge, practice, and perception.

Cywilnoprawne granice optymalizacji podatkowej w zakresie podatku dochodowego od osób prawnych (analiza struktur planowania podatkowego)

Wydział Prawa i Administracji

Implementation of enhanced recovery after surgery (ERAS) in colorectal surgery is highly cost-effective

Objective: Enhanced Recovery After Surgery (ERAS) clinical pathways in¦colorectal surgery are known to reduce postoperative complications leading¦to shortened hospital stay. However, the implementation of such an ERAS¦pathway requires time and financial investment. This study evaluates whether¦the savings related to the reduction in the length of stay (LOS) outweigh the¦costs of implementing an ERAS pathway.¦Methods: An ERAS pathway was implemented in our institution for colorectal¦surgery. The first 50 consecutive patients subjected to this ERAS pathway¦(ERAS group) were compared to 50 consecutive patients that were operated one¦year before its introduction (control group). Primary LOS, readmission within¦30 days, and total costs based on costs per day were compared. The mean costs¦per day were: 3,263 CHF for intensive care, 1,152 CHF for intermediate care,¦and 728 CHF for basic care.¦Results: Primary LOS was shorter in the ERAS group than in the control¦group: median 7 (interquartile range 5-12·25) versus 10 (7-18) days (P =¦0·0025). The readmission within 30 postoperative days was similar in both¦groups (2 patients each). In the ERAS group, the added primary LOS was¦485 days (379 in basic care, 99 in intermediate care, 7 in intensive care) compared¦to 706 days in the control group (533 in basic care, 146 in intermediate care,¦27 in intensive care). The total costs were significantly lower for the 50 ERAS¦patients compared to the control group: 412,801 CHF versus 644,317 CHF (P <¦0·01). Investments required for the 50 first ERAS patients were approximately¦83,544 CHF, including 348 working hours as well a full-time ERAS dedicated¦nurse. The overall cost saving was approximately 2,959 CHF per patient.¦Conclusion: Implementation of an ERAS pathway significantly reduced LOS¦after colorectal surgery. The financial investment to introduce and maintain¦such a pathway is clearly inferior to the cost-saving of reduced hospital stay.

How single is ‘single’ : some pragmatic reflections on single versus multifaceted interventions to facilitate implementation

An earlier overview of systematic reviews and a subsequent editorial on single-component versus multifaceted interventions to promote knowledge translation (KT) highlight complex issues in implementation science. In this supplemented commentary, further aspects are in focus; we propose examples from (KT) studies probing the issue of single interventions. A main point is that defining what is a single and what is a multifaceted intervention can be ambiguous, depending on how the intervention is conceived. Further, we suggest additional perspectives in terms of strategies to facilitate implementation. More specifically, we argue for a need to depict not only what activities are done in implementation interventions, but to unpack functions in particular contexts, in order to support the progress of implementation science.