A whole-health-economy approach to antimicrobial stewardship: Analysis of current models and future direction.

Antimicrobial stewardship (AMS) strategies are widely implemented in single healthcare sectors and organisations; however, the extent and impact of integrated AMS initiatives across the whole health economy are unknown. Assessing degree of integration of AMS across the whole health economy and its impact is essential if we are to achieve a ‘One Health’ approach to addressing antimicrobial resistance (AMR), and therefore we searched systematically for and analysed published examples of integrated AMS initiatives to address this gap. Application of a system-level framework to analyse integration of AMS initiatives across and within healthcare sectors shows that integration is emerging but needs strengthening. Findings from a small number of evaluations in high-income countries suggest that antimicrobial prescribing and healthcare-associated infections can be reduced using a multisectoral integrated AMS approach. More robust research designs to evaluate and understand the impact of multisectoral integrated AMS are needed, particularly with respect to differing health systems in different countries and local organisational contexts. Our analysis highlights a number of challenges and ways forward for enhancing the delivery of AMS through an integrated approach

A Process Modelling Framework Based on Point Interval Temporal Logic with an Application to Modelling Patient Flows

This thesis considers an application of a temporal theory to describe and model the patient journey in the hospital accident and emergency (A&E) department. The aim is to introduce a generic but dynamic method applied to any setting, including healthcare. Constructing a consistent process model can be instrumental in streamlining healthcare issues. Current process modelling techniques used in healthcare such as flowcharts, unified modelling language activity diagram (UML AD), and business process modelling notation (BPMN) are intuitive and imprecise. They cannot fully capture the complexities of the types of activities and the full extent of temporal constraints to an extent where one could reason about the flows. Formal approaches such as Petri have also been reviewed to investigate their applicability to the healthcare domain to model processes. Additionally, to schedule patient flows, current modelling standards do not offer any formal mechanism, so healthcare relies on critical path method (CPM) and program evaluation review technique (PERT), that also have limitations, i.e. finish-start barrier. It is imperative to specify the temporal constraints between the start and/or end of a process, e.g., the beginning of a process A precedes the start (or end) of a process B. However, these approaches failed to provide us with a mechanism for handling these temporal situations. If provided, a formal representation can assist in effective knowledge representation and quality enhancement concerning a process. Also, it would help in uncovering complexities of a system and assist in modelling it in a consistent way which is not possible with the existing modelling techniques. The above issues are addressed in this thesis by proposing a framework that would provide a knowledge base to model patient flows for accurate representation based on point interval temporal logic (PITL) that treats point and interval as primitives. These objects would constitute the knowledge base for the formal description of a system. With the aid of the inference mechanism of the temporal theory presented here, exhaustive temporal constraints derived from the proposed axiomatic system’ components serves as a knowledge base. The proposed methodological framework would adopt a model-theoretic approach in which a theory is developed and considered as a model while the corresponding instance is considered as its application. Using this approach would assist in identifying core components of the system and their precise operation representing a real-life domain deemed suitable to the process modelling issues specified in this thesis. Thus, I have evaluated the modelling standards for their most-used terminologies and constructs to identify their key components. It will also assist in the generalisation of the critical terms (of process modelling standards) based on their ontology. A set of generalised terms proposed would serve as an enumeration of the theory and subsume the core modelling elements of the process modelling standards. The catalogue presents a knowledge base for the business and healthcare domains, and its components are formally defined (semantics). Furthermore, a resolution theorem-proof is used to show the structural features of the theory (model) to establish it is sound and complete. After establishing that the theory is sound and complete, the next step is to provide the instantiation of the theory. This is achieved by mapping the core components of the theory to their corresponding instances. Additionally, a formal graphical tool termed as point graph (PG) is used to visualise the cases of the proposed axiomatic system. PG facilitates in modelling, and scheduling patient flows and enables analysing existing models for possible inaccuracies and inconsistencies supported by a reasoning mechanism based on PITL. Following that, a transformation is developed to map the core modelling components of the standards into the extended PG (PG*) based on the semantics presented by the axiomatic system. A real-life case (from the King’s College hospital accident and emergency (A&E) department’s trauma patient pathway) is considered to validate the framework. It is divided into three patient flows to depict the journey of a patient with significant trauma, arriving at A&E, undergoing a procedure and subsequently discharged. Their staff relied upon the UML-AD and BPMN to model the patient flows. An evaluation of their representation is presented to show the shortfalls of the modelling standards to model patient flows. The last step is to model these patient flows using the developed approach, which is supported by enhanced reasoning and scheduling

Spatial accessibility and social inclusion: The impact of Portugal's last health reform

Health policies seek to promote access to health care and should provide appropriate geographical accessibility to each demographical functional group. The dispersal demand of health‐careservices and the provision for such services atfixed locations contribute to the growth of inequality intheir access. Therefore, the optimal distribution of health facilities over the space/area can lead toaccessibility improvements and to the mitigation of the social exclusion of the groups considered mostvulnerable. Requiring for such, the use of planning practices joined with accessibility measures. However,the capacities of Geographic Information Systems in determining and evaluating spatial accessibility inhealth system planning have not yet been fully exploited. This paper focuses on health‐care services planningbased on accessibility measures grounded on the network analysis. The case study hinges on mainlandPortugal. Different scenarios were developed to measure and compare impact on the population'saccessibility. It distinguishes itself from other studies of accessibility measures by integrating network data ina spatial accessibility measure: the enhanced two‐stepfloating catchment area. The convenient location forhealth‐care facilities can increase the accessibility standards of the population and consequently reducethe economic and social costs incurred. Recently, the Portuguese government implemented a reform thataimed to improve, namely, the access and equity in meeting with the most urgent patients. It envisaged,in terms of equity, the allocation of 89 emergency network points that ensured more than 90% of thepopulation be within 30 min from any one point in the network. Consequently, several emergency serviceswere closed, namely, in rural areas. This reform highlighted the need to improve the quality of the emergencycare, accessibility to each care facility, and equity in their access. Hence, accessibility measures becomean efficient decision‐making tool, despite its absence in effective practice planning. According to anapplication of this type of measure, it was possible to verify which levels of accessibility were decreased,including the most disadvantaged people, with a larger time of dislocation of 12 min between 2001 and 2011

Unleashing Top-of-License Registered Nurse Practice: An Integrative Review

In light of a well-renowned report, “The Future of Nursing” released by the Institute of Medicine (2010), recommendations were suggested that nurses should practice at, and to, the full extent of their licensure, also referred to as top-of-license nursing practice. Transforming nursing care models coupled with strong leadership support is critical to fostering an environment where top-of-license practice can be fully achieved and sustained. This integrative review provides a compilation and synthesis of the available published evidence regarding the best practices for fostering environments conducive to top-of-license nursing practice. Results of these studies strongly supports the notion of nurses practicing to the full extent of their education and training

What You Need to Know about Bar-Code Medication Administration

Medication errors are the most common type of preventable error. Bar-code medication administration (BCMA) technology was designed to reduce medication administration errors. Poor system design, implementation and workarounds remain a cause of errors. This paper reviews the literature on BCMA, identifies a gap in the findings and identifies three evidence based practices that could be used to improve system implementation and reduce error. The literature review identified that Bar-code medication administration and system workarounds are well documented and affect patient safety. Based on the critical analysis of 10 studies, we identified gaps in the standardization of BCMA planning, implementation, and sustainability. The themes that emerged from the literature were poor BCMA design and implementation that resulted in workarounds.The three evidence based strategies proposed to address this gap are, evidence based standardization in planning and implementation, the identification and elimination of workarounds and hard wiring. An evidence based checklist evaluates compliance with standard procedures. The LEAN model of Jodoka is used to assure adaptation of the machine to human workflow. Direct observation provides valuable workflow assessment. An effective BCMA implementation involves careful system design, identification of workflow issues which cause workarounds, and adapting the machine to nursing needs