Systematic review of factors influencing length of stay in ICU after adult cardiac surgery

Intensive care unit (ICU) care is associated with costly and often scarce resources. In many parts of the world, ICUs are being perceived as major bottlenecks limiting downstream services such as operating theatres. There are many clinical, surgical and contextual factors that influence length of stay. Knowing these factors can facilitate resource planning. However, the extent at which this knowledge is put into practice remains unclear. The aim of this systematic review was to identify factors that impact the duration of ICU stay after cardiac surgery and to explore evidence on the link between understanding these factors and patient and resource management.We conducted electronic searches of Embase, PubMed, ISI Web of Knowledge, Medline and Google Scholar, and reference lists for eligible studies.Twenty-nine papers fulfilled inclusion criteria. We recognised two types of objectives for identifying influential factors of ICU length of stay (LOS) among the reviewed studies. These were general descriptions of predictors and prediction of prolonged ICU stay through statistical models. Among studies with prediction models, only two studies have reported their implementation. Factors most commonly associated with increased ICU LOS included increased age, atrial fibrillation/ arrhythmia, chronic obstructive pulmonary disease (COPD), low ejection fraction, renal failure/ dysfunction and non-elective surgery status.Cardiac ICUs are major bottlenecks in many hospitals around the world. Efforts to optimise resources should be linked to patient and surgical characteristics. More research is needed to integrate patient and surgical factors into ICU resource planning

Stress on the Ward – An Empirical Study of the Nonlinear Relationship between Organizational Workload and Service Quality

We discuss the impact of organizational workload on professional service outcomes, such as survival rates in hospitals. The prevailing view in the literature is that service quality deteriorates when organizational workload increases. In contrast, we argue that the relationship between workload and service outcomes is nonlinear and that there is a quality-optimal workload level. Whilst outcomes deteriorate with increasing workload when workload levels are already high, they will improve if workload increases from a low level. We reach this hypothesis by combining three perspectives: (i) the queuing theory perspective, with its focus on congestion, (ii) a discretionary choice perspective, with a focus on decisions made by professionals in response to changes in workload, and (iii) an endocrinological perspective, with a focus on the subconscious eff ects of workload on worker performance through the cognitive impact of stress hormones. Using a patient census of 1.4 million patients in 624 departments across 101 hospitals, we provide empirical support for the nonlinearity hypothesis in the context of hospital survival rates. We further discuss the implications for hospital capacity planning and the wider implications for service operations management.Service quality; service outcomes; organizational workload; hospital capacity planning; behavioral operations; stress

Context-Aware Multi-Agent Planning in intelligent environments

A system is context-aware if it can extract, interpret and use context information and adapt its functionality to the current context of use. Multi-agent planning generalizes the problem of planning in domains where several agents plan and act together, and share resources, activities, and goals. This contribution presents a practical extension of a formal theoretical model for Context-Aware Multi-Agent Planning based upon an argumentationbased defeasible logic. Our framework, named CAMAP, is implemented on a platform for open multiagent systems and has been experimentally tested, among others, in applications of ambient intelligence in the field of health-care. CAMAP is based on a multi-agent partial-order planning paradigm in which agents have diverse abilities, use an argumentation-based defeasible contextual reasoning to support their own beliefs and refute the beliefs of the others according to their context knowledge during the plan search process. CAMAP shows to be an adequate approach to tackle ambient intelligence problems as it gathers together in a single framework the ability of planning while it allows agents to put forward arguments that support or argue upon the accuracy, unambiguity and reliability of the context-aware information.This work is mainly supported by the Spanish Ministry of Science and Education under the FPU Grant Reference AP2009-1896 awarded to Sergio Pajares Ferrando, and Projects, TIN2011-27652-C03-01, and Consolider Ingenio 2010 CSD2007-00022.Pajares Ferrando, S.; Onaindia De La Rivaherrera, E. (2013). Context-Aware Multi-Agent Planning in intelligent environments. Information Sciences. 227:22-42. https://doi.org/10.1016/j.ins.2012.11.021S224222

Human-Computer Interaction in Mobile Context : A Cognitive Resources Perspective

Human-computer interaction is currently shifting its focus from desktop-based interaction to interaction with "beyond the desktop", which is embedded into everyday activities. In order to support users more elegantly, these mobile, wearable, and ubiquitous computing devices are envisioned to adapt inte lligently to their context. Thus far, however, the mobile use contexts per se have received attention, as most research has been technology-driven. Drawing from cognitive psychology, user modeling in human-computer interaction, and ethnomethodology, a framework is put forward here to analyse mobile use situations from the point of view of resource competition. The framework assumes that mobility is inherently multitasking and easily leads to competition for cognitive and other human resources. This "cognitive resource competition" framework is elaborated and associated with the psychological principles of capacity and multitasking. It looks at the typical social, interactional, cognitive, and physical tasks in mobility, relates them to the typical cognitive resources they compete for, and, based on known capacities of cognitive faculties, pinpoints restrictions and resources for action that can emerge in a given mobile situation. It is argued that the approach is useful for identifying the perceptual, attentional, and cognitive capabilities of a user in a mobile situation. The approach has implications for the design and innovation of intelligent, context-sensitive user interfaces and services. Furthermore, a practical method for making human resources visible in a design session is proposed and evaluated

Reduction of Centers for Medicare and Medicaid Services Reimbursement Penalty Risk

Healthcare centers face increasing revenue risk under the Medicare Access and Children\u27s Health Insurance Program Reauthorization Act (MACRA). The purpose of this multiple case study was to explore strategies that successful leaders of healthcare centers use to mitigate the risk of reimbursement penalties under MACRA. The conceptual framework of this study was Generation 3 cultural-historical activity theory (CHAT-III), and the analysis process used was Yin\u27s recursive and iterative phases. Participants of this study were 6 leaders of healthcare centers in the United States identified as having high quality and low cost via the Centers for Medicare and Medicaid public use files. Semistructured interviews were used to explore the identification of strategic opportunity, strategy formation, implementation, and control. Themes for organizational culture that emerged from data analysis included a foundation core with flexibility and iterative process-improvement practice. Themes in the strategy formation process included total employee involvement and a quality-first, cost-benefit strategy structure. Themes in the implementation process included multiple departmental and organizational collaboration, task-based implementation, and data transparency. Localized cadence meetings were a theme in the control process. Improvements to the organization as a result of this study include a series of standards for organizational culture, a toolbox including CHAT-III as a tool for the identification of strategic opportunity and a methodology for strategy formation and implementation, and control to help ensure financial sustainability. Implications for positive social change include the increased probability of continued ready access to healthcare, improved population health, and lower mortality rates for the communities served

Small scale embedded generation (SSEG) in Cape Town: a case study on the impact of Cape Town's SSEG regulation

In recent years, the rapidly diminishing costs of renewable technologies have rendered solar photovoltaics (PV) price competitive at a range of scales. Globally, there has been an increasing proliferation of distributed renewable generation embedded within the electricity network, called Small-Scale Embedded Generation (SSEG). Yet, while such decentralised technologies have taken a central role in discussions on energy transitions in the Global North, their implications in the Global South remain poorly documented. In South Africa, the convergence of a legacy energy system, supply issues, rising electricity prices, and growing environmental awareness as well as rapid urbanisation and persistent poverty is presenting a set of compound challenges for government at all levels and threatens the transition to a sustainable, low-carbon energy system. This study investigates the implications of SSEG on Cape Town's energy transition and assesses the drivers and impacts of regulatory responses. The study adopts a multi-level perspective on sociotechnical transitions deployed at the municipal scale to explore the role of SSEG in a just and sustainable energy transition. This was done along three dimensions using an environmental justice framework proposed by Cock (2004), wherein a green agenda refers to environmental conservation, a brown agenda represents energy impacts on quality of life and development, and a red agenda represents social justice and equality. Achieving a just transition will require attention to each of the three agendas in this framework. Using data from a desktop analysis, policy review and ten semi-structured interviews to investigate the case of Cape Town, the study found that the impacts of SSEG are dependent on the contextual landscape within which this transition is situated. Regulation of SSEG is largely the result of municipal attempts to protect its financial ability to fulfil developmental mandates. Recent regulatory developments have resulted in several unintended consequences which have reduced the extent to which green energy is equitably distributed across the municipal grid, and failed to mitigate revenue impacts of SSEG, and consequently the ability of municipalities to continue developmental agendas. National landscape pressures from increasing electricity prices and continued load-shedding are driving SSEG uptake. In response to these pressures, and municipal regulation, SSEG has adapted to new niches and battery technologies have become increasingly prevalent. Left unregulated SSEG will continue to threaten the financial viability of municipalities and the extent to which the ongoing energy transition in South Africa will be just and equitable. This study contributes to an emerging social-science research agenda into socio-technical transitions and addresses the limited consideration of the implications of disruptive technologies and their regulation at the city regime scale in the Global South