Quality Improvement Cycles that Reduced Waiting Times at Tshwane District Hospital Emergency Department

Background: Tshwane District Hospital (TDH) is a level-one hospital, delivering services in the centre of Pretoria since February 2006. It is unique in location, being only 100 meters away from the tertiary hospital, Pretoria Academic Hospital (PAH). In South Africa, public sector emergency units are under enormous pressure with large patient numbers, understaffing and poor resources. TDH Emergency Department (ED) is a typical example. An average of 3 900 patients per month visited this ED in 2006. Recurrent complaints and dissatisfaction shown by the patients about prolonged waiting times before consulting the medical practitioners (MPs) in the ED were one of the initial challenges faced by the newly established hospital. It was decided to undertake quality improvement (QI) cycles to analyse and improve the situation, using waiting time as a measure of improvement. Methods: A QI team was chosen to conduct two QI cycles. The allocated time for QI cycle 1 was from May to August 2006 and for QI cycle 2 from September to December 2006. A total of 150 waiting times of stable and unstable patients were evaluated. Fifty waiting times were recorded over a span of 24 hours for each data collection in May, September and December 2006. Waiting time was defined as the time from arrival of the patient in the unit until the start of the consultation by the MP. Surveys were done in May and September to analyse the problems causing prolonged waiting times. The implemented change included instituting a functional triage system, improvement of the process of up- and down-referrals to and from the tertiary hospital, easy access to stock, reorganisation of doctors' duty roster, reorganisation of the academic programme, announcement on waiting time to patients, nurses carrying out minor procedures and availability of reference books. Results: The median waiting times for stable patients were as follows: May 2006: 545 minutes (range 200 to 1 260), September 2006: 230 minutes (range 15 to 480) and December 2006: 89 minutes (range 15 to 230). There was a significant difference among these waiting times for May, September and December 2006 (p < 0.001; Kruskal-Wallis H test). The median waiting times for unstable patients were as follows: May 2006: zero minutes (range 0 to 30), September 2006: zero minutes (range 0 to 3) and December 2006: 0.5 minutes (range 0 to 2). There was no difference among the waiting times for unstable patients for May, September and December 2006 (p = 0.90; Kruskal-Wallis H test). Conclusion: This QI exercise identified problems causing prolonged waiting time for stable patients at TDH ED. It rectified most of the identified problems. However, goals regarding registration and laboratory delays could not be successfully achieved. This study showed the significance of QI cycles in improving waiting times for stable patients at TDH ED without any additional financial or human resources. This was done without compromising the time taken to see unstable patients. South African Family Practice Vol. 50 (6) 2008: pp. 43-43

Communication skills for medical/dental students at the University of Pretoria: lessons learnt from a two-year study using a forum theatre method

Background: This study describes the lessons learnt from using a novel method for teaching communication skills to second-year medical/dental students.Methods: Medical and drama teachers designed this action research project to serve the educational interests of secondyear medical/dental and drama students. The drama students enacted problematic doctor-patient scenarios for their forum theatre course. The interactive enactment was done for groups of 60-70 medical/dental students. The latter interrupted the actors to suggest improved communication skills. The drama students then re-enacted the scenarios, incorporating the improvements. The medical/dental students\' knowledge of communication skills was assessed before the enactment, three weeks later, and again four months after that. Their semi-structured feedback was analysed thematically. In the next year, the feedback was used to improve the methodology for the new second-year students. Results: In both years, the medical/dental students\' knowledge showed a statistically significant improvement after the enactment, and this was sustained for four months. In year 1, the feedback revolved around language problems and disrespectful attitudes. In year 2, visual cue cards of the communication skills were displayed during the act, and the drama students emphasised these rather than attitudinal problems. However, feedback showed that caricaturing the doctors\' attitudes still detracted attention from the desired focus on communication skills. Conclusions: Although the forum theatre method can transfer knowledge of communication skills, the focus of the acting should be on the demonstration of inappropriate communication skills rather than inappropriate attitudes. One limitation of this study is that assessment was limited to knowledge and did not progress to skills. South African Family Practice Vol. 47(6) 2005: 60-6

Is temperament a key to the success of teaching innovation?

Introduction. A section of the undergraduate curriculum was revised due to consistently poor student evaluation. The chosen didactic method for achieving this change was reciprocal peer teaching. This innovation may have required academic members of staff to adapt to a new teaching style. Method. Staff members determined their Keirsey temperament and were given a report on its interpretation. They participated in training on student-focused teaching techniques and completed the Approaches to Teaching Inventory (ATI) of their preferred approach to teaching. Their subsequent sessions with students were videotaped and analysed for features of student-focused, as opposed to teacher-focused, teaching. Results. There was a link between temperament type and apparent delivery of student-focused teaching. Staff members&rsquo; perceptions of their approach to teaching did not correspond to their actual teaching behaviour. Discussion. Staff development strategies could take into account individual temperaments in order to direct their professional development for the full spectrum of flexible teaching skills. Alternatively, teaching teams should be created in a way that takes account of different temperament types. Conclusion. Temperament does play a key role in adaptation to innovation

Three obstructions: forms of causation, chronotopoids, and levels of reality

The thesis is defended that the theories of causation, time and space, and levels of reality are mutually interrelated in such a way that the difficulties internal to theories of causation and to theories of space and time can be understood better, and perhaps dealt with, in the categorial context furnished by the theory of the levels of reality. The structural condition for this development to be possible is that the first two theories be opportunely generalized

Cold gas accretion in galaxies

Evidence for the accretion of cold gas in galaxies has been rapidly accumulating in the past years. HI observations of galaxies and their environment have brought to light new facts and phenomena which are evidence of ongoing or recent accretion: 1) A large number of galaxies are accompanied by gas-rich dwarfs or are surrounded by HI cloud complexes, tails and filaments. It may be regarded as direct evidence of cold gas accretion in the local universe. It is probably the same kind of phenomenon of material infall as the stellar streams observed in the halos of our galaxy and M31. 2) Considerable amounts of extra-planar HI have been found in nearby spiral galaxies. While a large fraction of this gas is produced by galactic fountains, it is likely that a part of it is of extragalactic origin. 3) Spirals are known to have extended and warped outer layers of HI. It is not clear how these have formed, and how and for how long the warps can be sustained. Gas infall has been proposed as the origin. 4) The majority of galactic disks are lopsided in their morphology as well as in their kinematics. Also here recent accretion has been advocated as a possible cause. In our view, accretion takes place both through the arrival and merging of gas-rich satellites and through gas infall from the intergalactic medium (IGM). The infall may have observable effects on the disk such as bursts of star formation and lopsidedness. We infer a mean ``visible'' accretion rate of cold gas in galaxies of at least 0.2 Msol/yr. In order to reach the accretion rates needed to sustain the observed star formation (~1 Msol/yr), additional infall of large amounts of gas from the IGM seems to be required.Comment: To appear in Astronomy & Astrophysics Reviews. 34 pages. Full-resolution version available at http://www.astron.nl/~oosterlo/accretionRevie

Molecular and cellular mechanisms underlying the evolution of form and function in the amniote jaw.

The amniote jaw complex is a remarkable amalgamation of derivatives from distinct embryonic cell lineages. During development, the cells in these lineages experience concerted movements, migrations, and signaling interactions that take them from their initial origins to their final destinations and imbue their derivatives with aspects of form including their axial orientation, anatomical identity, size, and shape. Perturbations along the way can produce defects and disease, but also generate the variation necessary for jaw evolution and adaptation. We focus on molecular and cellular mechanisms that regulate form in the amniote jaw complex, and that enable structural and functional integration. Special emphasis is placed on the role of cranial neural crest mesenchyme (NCM) during the species-specific patterning of bone, cartilage, tendon, muscle, and other jaw tissues. We also address the effects of biomechanical forces during jaw development and discuss ways in which certain molecular and cellular responses add adaptive and evolutionary plasticity to jaw morphology. Overall, we highlight how variation in molecular and cellular programs can promote the phenomenal diversity and functional morphology achieved during amniote jaw evolution or lead to the range of jaw defects and disease that affect the human condition

Style, Function and Cultural Transmission

Recent evolutionary approaches to the understanding of lithic variability take us back to long-standing issues in lithic studies to do with the claimed contrast between style and function and the Binford-Bordes debate of the 1960s concerning the factors that affect inter-assemblage variation. In fact, the style and function contrast is an unhelpful one, not least when considering the question of convergence. Taking the definition of style as ‘a way of doing’, all functions are carried out in locally specific ways that have a transmission history, although the extent to which the history of the attributes relevant to the function have been subject to random drift and innovation patterns, as opposed to selection, will vary. Moreover, in a subtractive technology like lithics the extent to which a transmission signal will be visible in an attribute like the angle of a cutting edge is unclear. The contrasting view is that, in the case of lithics, functional requirements will always call into existence the technical innovations to satisfy them, which in any case are not that difficult to find. The paper addresses these and related issues with reference to previous work by Shennan and colleagues on the use of material culture to identify within and between group variation, the extent to which isolation-by-distance in space and time can account for the similarities and differences between assemblages, and the role of phylogenetic methods

Masking of Figure-Ground Texture and Single Targets by Surround Inhibition: A Computational Spiking Model

A visual stimulus can be made invisible, i.e. masked, by the presentation of a second stimulus. In the sensory cortex, neural responses to a masked stimulus are suppressed, yet how this suppression comes about is still debated. Inhibitory models explain masking by asserting that the mask exerts an inhibitory influence on the responses of a neuron evoked by the target. However, other models argue that the masking interferes with recurrent or reentrant processing. Using computer modeling, we show that surround inhibition evoked by ON and OFF responses to the mask suppresses the responses to a briefly presented stimulus in forward and backward masking paradigms. Our model results resemble several previously described psychophysical and neurophysiological findings in perceptual masking experiments and are in line with earlier theoretical descriptions of masking. We suggest that precise spatiotemporal influence of surround inhibition is relevant for visual detection

Feed-Forward Segmentation of Figure-Ground and Assignment of Border-Ownership

Figure-ground is the segmentation of visual information into objects and their surrounding backgrounds. Two main processes herein are boundary assignment and surface segregation, which rely on the integration of global scene information. Recurrent processing either by intrinsic horizontal connections that connect surrounding neurons or by feedback projections from higher visual areas provide such information, and are considered to be the neural substrate for figure-ground segmentation. On the contrary, a role of feedforward projections in figure-ground segmentation is unknown. To have a better understanding of a role of feedforward connections in figure-ground organization, we constructed a feedforward spiking model using a biologically plausible neuron model. By means of surround inhibition our simple 3-layered model performs figure-ground segmentation and one-sided border-ownership coding. We propose that the visual system uses feed forward suppression for figure-ground segmentation and border-ownership assignment