(OR, 0.49; 95% CI, 0.36‐0.67), respiratory failure (OR, 0.40; 95% CI, 0.27‐0.59), and cardiac arrest (OR, 0.72; 95% CI, 0.62‐0.84) in ICUs, with a lower risk of failure to rescue (OR, 0.84; 95% CI, 0.79‐0.90) in surgical patients. Length of stay was shorter by 24% in ICUs (OR, 0.76; 95% CI, 0.62‐0.94) and by 31% in surgical patients (OR, 0.69; 95% CI, 0.55‐0.86). Conclusions: Studies with different design show associations between increased RN staffing and lower odds of hospital related mortality and adverse patient events. Patient and hospital characteristics, including hospitals’ commitment to quality of medical care, likely contribute to the actual causal pathway.

http://www.safestaffing.org.uk/shared/cms/file.asp?e=35&i=187801

The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis.

About 1 in 5 Medicare fee-for-service patients discharged from the hospital is rehospitalized within 30 days In this systematic review of 43 studies evaluating interventions to reduce readmission 

Interventions to Reduce 30-Day Rehospitalization: A Systematic Review

Background
Clinical pathways are structured multidisciplinary care plans used by health services to detail essential steps in the care of patients with a specific clinical problem. They aim to link evidence to practice and optimise clinical outcomes whilst maximising clinical efficiency.

Objectives
To assess the effect of clinical pathways on professional practice, patient outcomes, length of stay and hospital costs.

Search methods
We searched the Database of Abstracts of Reviews of Effectiveness (DARE), the Effective Practice and Organisation of Care (EPOC) Register, the Cochrane Central Register of Controlled Trials (CENTRAL) and bibliographic databases including MEDLINE, EMBASE, CINAHL, NHS EED and Global Health. We also searched the reference lists of relevant articles and contacted relevant professional organisations.

Selection criteria
Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series studies comparing stand alone clinical pathways with usual care as well as clinical pathways as part of a multifaceted intervention with usual care.

Data collection and analysis
Two review authors independently screened all titles to assess eligibility and methodological quality. Studies were grouped into those comparing clinical pathways with usual care and those comparing clinical pathways as part of a multifaceted intervention with usual care.

Main results
Twenty-seven studies involving 11,398 participants met the eligibility and study quality criteria for inclusion. Twenty studies compared stand alone clinical pathways with usual care. These studies indicated a reduction in in-hospital complications (odds ratio (OR) 0.58; 95% confidence interval (CI) 0.36 to 0.94) and improved documentation (OR 11.95: 95%CI 4.72 to 30.30). There was no evidence of differences in readmission to hospital or in-hospital mortality. Length of stay was the most commonly employed outcome measure with most studies reporting significant reductions. A decrease in hospital costs/ charges was also observed, ranging from WMD +261 US$ favouring usual care to WMD -4919 US$ favouring clinical pathways (in US$ dollar standardized to the year 2000). Considerable heterogeneity prevented meta-analysis of length of stay and hospital cost results.  An assessment of whether lower hospital costs contributed to cost shifting to another health sector was not undertaken.

Seven studies compared clinical pathways as part of a multifaceted intervention with usual care. No evidence of differences were found between intervention and control groups.

Authors' conclusions
Clinical pathways are associated with reduced in-hospital complications and improved documentation without negatively impacting on length of stay and hospital costs.

/pdf/clinical-pathways-effects-on-professional-practice-patient-2sl6tkljsx.pdf

Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs

Objectives To review important patient safety practices for evidence of effectiveness, implementation, and adoption. Data sources Searches of multiple computerized databases, gray literature, and the judgments of a 20-member panel of patient safety stakeholders. Review methods The judgments of the stakeholders were used to prioritize patient safety practices for review, and to select which practices received in-depth reviews and which received brief reviews. In-depth reviews consisted of a formal literature search, usually of multiple databases, and included gray literature, where applicable. In-depth reviews assessed practices on the following domains: • How important is the problem? • What is the patient safety practice? • Why should this practice work? • What are the beneficial effects of the practice? • What are the harms of the practice? • How has the practice been implemented, and in what contexts? • Are there any data about costs? • Are there data about the effect of context on effectiveness? We assessed individual studies for risk of bias using tools appropriate to specific study designs. We assessed the strength of evidence of effectiveness using a system developed for this project. Brief reviews had focused literature searches for focused questions. All practices were then summarized on the following domains: scope of the problem, strength of evidence for effectiveness, evidence on potential for harmful unintended consequences, estimate of costs, how much is known about implementation and how difficult the practice is to implement. Stakeholder judgment was then used to identify practices that were "strongly encouraged" for adoption, and those practices that were "encouraged" for adoption. Results From an initial list of over 100 patient safety practices, the stakeholders identified 41 practices as a priority for this review: 18 in-depth reviews and 23 brief reviews. Of these, 20 practices had their strength of evidence of effectiveness rated as at least "moderate," and 25 practices had at least "moderate" evidence of how to implement them. Ten practices were classified by the stakeholders as having sufficient evidence of effectiveness and implementation and should be "strongly encouraged" for adoption, and an additional 12 practices were classified as those that should be "encouraged" for adoption. Conclusions The evidence supporting the effectiveness of many patient safety practices has improved substantially over the past decade. Evidence about implementation and context has also improved, but continues to lag behind evidence of effectiveness. Twenty-two patient safety practices are sufficiently well understood, and health care providers can consider adopting them now.

Making health care safer II: an updated critical analysis of the evidence for patient safety practices.

Encyclopedia of Information Science and Technology

Strengths and weaknesses of modern wide-bandwidth bipolar transistor operational amplifiers are investigated and compared with respect to bandwidth, slew rate, noise, distortion, and power This paper traces the evolution of operational amplifier designs since vacuum tube days to give a perspective of the large number of circuit variations used over time Of particular value is the ability to use many of these circuit design options as the basis of new amplifiers In addition, an array of operational amplifier components fabricated on the AT&T CBIC V2 process is described This design incorporates many of the architectural techniques that have evolved over the years to produce four separate operational amplifier on a single base wafer The process design methodology requires identifying the common elements in each architecture and the minimum number of additional components required to implement four unique architectures on the array >

Evolution of high-speed operational amplifier architectures

Industrial accidents are a major concern for companies and families alike. It is a high priority to all stakeholders that steps be taken to prevent accidents from occurring. In this paper, three approaches to safety are examined: fault trees (FT), Bayesian networks (BN), and the Functional Resonance Analysis Method (FRAM). A case study of a propane feed control system is used to apply these methods. In order to make safety improvements to industrial workplaces high understanding of the systems is required. It is shown that consideration of the chance of failure of the system components, as in the FT and BN approaches, may not provide enough understanding to fully inform safety assessments. The FT and BN methods are top-down approaches that are formed from the perspective of management in workplaces. The FRAM methodology uses a bottom-up approach from the operational perspective to improve the understanding of the industrial workplace. The FRAM approach can provide added insight to the human factor and context and increase the rate at which we learn by considering successes as well as failures. FRAM can be a valuable tool for industrial safety assessment and to consider industrial safety holistically, by providing a framework to examine the operations in detail. However, operations should be considered using both top-down and bottom-up perspectives and all operational experience to make the most informed safety decisions.

Understanding industrial safety: Comparing Fault tree, Bayesian network, and FRAM approaches

Review of risk-based design for ice-class ships

Inpatient discharge surveys at Middlemore hospital, a 600 bed hospital in South Auckland, New Zealand, consistently rate communication and co-ordination of care as parameters in need of improvement. A case management model of care was suggested as a means of achieving this. The objective of this study was to determine the effectiveness of care co-ordination in an acute general medical setting in a pilot study over a 4 week period. A care co-ordinator identified 18 patients with complex problems among 48 patients admitted to a single medical ward under the care of a single multidisciplinary team, with their care being co-ordinated over the entire episode of illness. A control group of 59 similarly complex patients admitted to other wards and teams without care co-ordination over the same period was also studied and the outcomes compared. Communication and co-ordination, discharge information, involvement in discharge planning and information on post-discharge services were rated by the study patients as good or very good by 77, 85, 69 and 77%, respectively, compared with 62, 30, 41 and 45% in the control group. The same parameters were rated as poor or very poor by 13, 30, 36 and 15% of the control patients, compared with 0% in all these measures in the study group. Twenty-one clinical staff involved in the study agreed that there was an improvement in care co-ordination with respect to efficiency, reduction of workload and better communication, with approval ratings being 71, 76 and 76%, respectively. There was no difference in Average Length of Stay between the control and study groups, but three of the patients in the control group may have had their preventable readmissions within 10 days avoided if their care had been co-ordinated during their initial admission.

Care co-ordination improves quality-of-care at South Auckland Health.

A major initiative to implement a clinical pathway for myocardial infarction has provided a model on which to further develop pathways within our organization. Two of the primary objectives were to reduce time to thrombolysis and length of stay. Two years after the implementation of the myocardial infarction pathway there has been a reduction in the thrombolysis times from 80 to 49 min and in length of stay from 7.28 to 6.13 days. These results highlight significant improvements in patient and process outcomes. There is heightened awareness about best practice for patients who have sustained myocardial infarctions.

Doug Smith

Papers

Evolution of high-speed operational amplifier architectures

Understanding industrial safety: Comparing Fault tree, Bayesian network, and FRAM approaches

Review of risk-based design for ice-class ships

Care co-ordination improves quality-of-care at South Auckland Health.

Towards excellence in quality patient care: a clinical pathway for myocardial infarction.