Statewide retrospective study of low acuity emergency presentations in New South Wales, Australia: who, what, where and why?

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/Abstract Objective The present study aims to use a statewide population-based registry to assess the prevalence of low acuity emergency department (ED) presentations, describe the trend in presentation rates and to determine whether they were associated with various presentation characteristics such as the type of hospital as well as clinical and demographic variables. Design and setting This was a retrospective analysis of a population-based registry of ED presentations in New South Wales (NSW). Generalised estimating equations with log links were used to determine factors associated with low acuity presentations to account for repeat presentations and the possibility of clustering of outcomes. Participants Patients were included in this analysis if they presented to an ED between January 2010 and December 2014. The outcomes of interest were low acuity presentation, defined as those who self-presented (were not transported by ambulance), were assigned a triage category of 4 or 5 (semiurgent or non-urgent) and discharged back to usual residence from ED. Results There were 10.7 million ED presentations analysed. Of these, 45% were classified as a low acuity presentation. There was no discernible increase in the rate of low acuity presentations across NSW between 2010 and 2014. The strongest predictors of low acuity ED presentation were age <40 years of age (OR 1.77); injury or musculoskeletal administrative and non-urgent procedures (OR 2.96); ear, nose and throat, eye or oral (OR 5.53); skin or allergy-type presenting problems (OR 2.84). Conclusions Low acuity ED presentations comprise almost half of all ED presentations. Alternative emergency models of care may help meet the needs of these patients

Fe-Mediated Nitrogen Fixation with a Metallocene Mediator: Exploring pK_a Effects and Demonstrating Electrocatalysis

Substrate selectivity in reductive multi-electron/proton catalysis with small molecules such as N_2, CO_2, and O_2 is a major challenge for catalyst design, especially where the competing hydrogen evolution reaction (HER) is thermodynamically and kinetically competent. In this study, we investigate how the selectivity of a tris(phosphine)borane iron(I) catalyst, P_3^BFe^+, for catalyzing the nitrogen reduction reaction (N_2RR, N_2-to-NH_3 conversion) versus HER changes as a function of acid pK_a. We find that there is a strong correlation between pKa and N_2RR efficiency. Stoichiometric studies indicate that the anilinium triflate acids employed are only compatible with the formation of early stage intermediates of N_2 reduction (e.g., Fe(NNH) or Fe(NNH_2)) in the presence of the metallocene reductant Cp*_2Co. This suggests that the interaction of acid and reductant is playing a critical role in N–H bond forming reactions. DFT studies identify a protonated metallocene species as a strong PCET donor and suggest that it should be capable of forming the early stage N–H bonds critical for N_2RR. Furthermore, DFT studies also suggest that the observed pK_a effect on N_2RR efficiency is attributable to the rate and thermodynamics, of Cp*_2Co protonation by the different anilinium acids. Inclusion of Cp*_2Co^+ as a co-catalyst in controlled potential electrolysis experiments leads to improved yields of NH_3. The data presented provide what is to our knowledge the first unambiguous demonstration of electrocatalytic nitrogen fixation by a molecular catalyst (up to 6.7 equiv NH_3 per Fe at −2.1 V vs Fc^(+/0))

Wearable sensor metric for fidgeting: screen engagement rather than interest causes NIMI of wrists and ankles

Measuring fidgeting is an important goal for the psychology of mind-wandering and for human computer interaction (HCI). Previous work measuring the movement of the head, torso and thigh during HCI has shown that engaging screen content leads to non-instrumental movement inhibition (NIMI). Camera-based methods for measuring wrist movements are limited by the occlusion, supination and friction of the arm. Here we used a high pass filtered magnitude of wearable tri-axial accelerometer recordings during 2-minute passive HCI stimuli as a surrogate for movement of the wrists and ankles. With 24 seated, healthy volunteers experiencing HCI, this metric showed that wrists moved significantly more than ankles. We found that NIMI could be detected in the wrists and ankles; it distinguished extremes of interest and boredom via restlessness. We conclude that both free-willed and forced screen engagement can elicit NIMI of the wrists and ankles

Making the user more efficient: Design for sustainable behaviour

User behaviour is a significant determinant of a product’s environmental impact; while engineering advances permit increased efficiency of product operation, the user’s decisions and habits ultimately have a major effect on the energy or other resources used by the product. There is thus a need to change users’ behaviour. A range of design techniques developed in diverse contexts suggest opportunities for engineers, designers and other stakeholders working in the field of sustainable innovation to affect users’ behaviour at the point of interaction with the product or system, in effect ‘making the user more efficient’. Approaches to changing users’ behaviour from a number of fields are reviewed and discussed, including: strategic design of affordances and behaviour-shaping constraints to control or affect energyor other resource-using interactions; the use of different kinds of feedback and persuasive technology techniques to encourage or guide users to reduce their environmental impact; and context-based systems which use feedback to adjust their behaviour to run at optimum efficiency and reduce the opportunity for user-affected inefficiency. Example implementations in the sustainable engineering and ecodesign field are suggested and discussed

Catalytic N_2-to-NH_3 Conversion by Fe at Lower Driving Force: A Proposed Role for Metallocene-Mediated PCET

We have recently reported on several Fe catalysts for N_2-to-NH_3 conversion that operate at low temperature (−78 °C) and atmospheric pressure while relying on a very strong reductant (KC_8) and acid ([H(OEt_2)_2][BArF_4]). Here we show that our original catalyst system, P_3^BFe, achieves both significantly improved efficiency for NH_3 formation (up to 72% for e^– delivery) and a comparatively high turnover number for a synthetic molecular Fe catalyst (84 equiv of NH_3 per Fe site), when employing a significantly weaker combination of reductant (Cp*_2Co) and acid ([Ph_2NH_2][OTf] or [PhNH_3][OTf]). Relative to the previously reported catalysis, freeze-quench Mössbauer spectroscopy under turnover conditions suggests a change in the rate of key elementary steps; formation of a previously characterized off-path borohydrido–hydrido resting state is also suppressed. Theoretical and experimental studies are presented that highlight the possibility of protonated metallocenes as discrete PCET reagents under the present (and related) catalytic conditions, offering a plausible rationale for the increased efficiency at reduced driving force of this Fe catalyst system

The Sydney Triage to Admission Risk Tool (START) to predict Emergency Department Disposition: A derivation and internal validation study using retrospective state-wide data from New South Wales, Australia.

BACKGROUND: Disposition decisions are critical to the functioning of Emergency Departments. The objectives of the present study were to derive and internally validate a prediction model for inpatient admission from the Emergency Department to assist with triage, patient flow and clinical decision making. METHODS: This was a retrospective analysis of State-wide Emergency Department data in New South Wales, Australia. Adult patients (age ≥ 16 years) were included if they presented to a Level five or six (tertiary level) Emergency Department in New South Wales, Australia between 2013 and 2014. The outcome of interest was in-patient admission from the Emergency Department. This included all admissions to short stay and medical assessment units and being transferred out to another hospital. Analyses were performed using logistic regression. Discrimination was assessed using area under curve and derived risk scores were plotted to assess calibration. RESULTS: 1,721,294 presentations from twenty three Level five or six hospitals were analysed. Of these 49.38% were male and the mean (sd) age was 49.85 years (22.13). Level 6 hospitals accounted for 47.70% of cases and 40.74% of cases were classified as an in-patient admission based on their mode of separation. The final multivariable model including age, arrival by ambulance, triage category, previous admission and presenting problem had an AUC of 0.82 (95% CI 0.81, 0.82). CONCLUSION: By deriving and internally validating a risk score model to predict the need for in-patient admission based on basic demographic and triage characteristics, patient flow in ED, clinical decision making and overall quality of care may be improved. Further studies are now required to establish clinical effectiveness of this risk score model

A trigger-substrate model for smiling during an automated formative quiz: engagement is the substrate, not frustration

INTRODUCTION: Automated tutoring systems aim to respond to the learner’s cognitive state in order to maintain engagement. The end-user’s state might be inferred by interactive timings, bodily movements or facial expressions. Problematic computerized stimuli are known to cause smiling during periods of frustration. METHODS: Forty-four seated, healthy participants (age range 18-35, 18 male) used a handheld trackball to answer a computer-presented, formative, 3-way multiple choice geography quiz, with 9 questions, lasting a total of 175 seconds. Frontal facial videos (10 Hz) were collected with a webcam and processed for facial expressions by CrowdEmotion using a pattern recognition algorithm. Interactivity was recorded by a keystroke logger (Inputlog 5.2). Subjective responses were collected immediately after each quiz using a panel of visual analogue scales (VAS). RESULTS: Smiling was fie-fold enriched during the instantaneous feedback segments of the quiz, and this was correlated with VAS ratings for engagement but not with happiness or frustration. Nevertheless, smiling rate was significantly higher after wrong answers compared to correct ones, and frustration was correlated with the number of questions answered incorrectly. CONCLUSION: The apparent disconnect between the increased smiling during incorrect answers but the lack of correlation between VAS frustration and smiles suggests a trigger-substrate model where engagement is the permissive substrate, while the noises made by the quiz after wrong answers may be the trigger