Identifying the challenges and facilitators of implementing a COPD care bundle.

BACKGROUND: Care bundles have been shown to improve outcomes, reduce hospital readmissions and reduce length of hospital stay; therefore increasing the speed of uptake and delivery of care bundles should be a priority in order to deliver more timely improvements and consistent high-quality care. Previous studies have detailed the difficulties of obtaining full compliance to bundle elements but few have described the underlying reasons for this. In order to improve future implementation this paper investigates the challenges encountered by clinical teams implementing a chronic obstructive pulmonary disease (COPD) care bundle and describes actions taken to overcome these challenges. METHODS: An initial retrospective documentary analysis of data from seven clinical implementation teams was undertaken to review the challenges faced by the clinical teams. Three focus groups with healthcare professionals and managers explored solutions to these challenges developed during the project. RESULTS: Documentary analysis identified 28 challenges which directly impacted implementation of the COPD care bundle within five themes; staffing, infrastructure, process, use of improvement methodology and patient and public involvement. Focus groups revealed that the five most significant challenges for all groups were: staff too busy, staff shortages, lack of staff engagement, added workload of the bundle and patient coding issues. The participants shared facilitating factors used to overcome issues including: shifting perceptions to improve engagement, further education sessions to increase staff participation and gaining buy-in from managers through payment frameworks. CONCLUSIONS: Maximising the impact of a care bundle relies on its successful and timely implementation. Teams implementing the COPD care bundle encountered challenges that were common to all teams and sites. Understanding and learning from the challenges faced by previous endeavours and identifying the facilitators to overcoming these barriers provides an opportunity to mitigate issues that waste time and resources, and ensures that training can be tailored to the anticipated challenges

Magnetic stars from a FEROS cool Ap star survey

New magnetic Ap stars with split Zeeman components are presented. These stars were discovered from observations with the Fibre-fed Extended Range Optical Spectrograph (FEROS) spectrograph at the European Southern Observatory (ESO) 2.2-m telescope. 15 new magnetic stars are analysed here. Several stars with very strong magnetic fields were found, including HD 70702 with a 15-kG magnetic field strength, and HD 168767 with a 16.5-kG magnetic field strength measured using split Zeeman components of spectral lines and by comparison with synthetic calculations. The physical parameters of the stars were estimated from photometric and spectroscopic data. Together with previously published results for stars with strong magnetic fields, the relationship between magnetic field strength and rotation period is discussed

The supply of information in an emotional setting

Advances in the field of economics and psychology have contributed greatly to the understanding of the supply of information when it affects the emotions and consequently the decisions made by two parties. Yet, these studies assume the parties have identical utilities. In this paper, focusing on the doctor-patient interaction, we relax the perfect agency assumption, introduce the agent’s effort in supplying information, and analyse the two parties' interdependent decisions under asymmetric information. We show that when the supplier of information fails to understand the receiver’s preferences the latter will disregard completely the recommendation. We consider the policy recommendations and welfare implications of the model

Impact of a COPD Discharge Care Bundle on Readmissions following Admission with Acute Exacerbation: Interrupted Time Series Analysis.

We evaluated the impact of a COPD discharge care bundle on readmission rates following hospitalisation with an acute exacerbation.Interrupted time series analysis, comparing readmission rates for COPD exacerbations at nine trusts that introduced the bundle, to two comparison groups; (1) other NHS trusts in London and (2) all other NHS trusts in England. Care bundles were implemented at different times for different NHS trusts, ranging from October 2009 to April 2011.Nine NHS acute trusts in the London, England.Patients aged 45 years and older admitted to an NHS acute hospital in England for acute exacerbation of COPD. Data come from Hospital Episode Statistics, April 2002 to March 2012.Annual trend readmission rates (and in total bed days) within 7, 28 and 90 days, before and after implementation.In hospitals introducing the bundle readmission rates were rising before implementation and falling afterwards (e.g. readmissions within 28 days +2.13% per annum (pa) pre and -5.32% pa post (p for difference in trends = 0.012)). Following implementation, readmission rates within 7 and 28 day were falling faster than among other trusts in London, although this was not statistically significant (e.g. readmissions within 28 days -4.6% pa vs. -3.2% pa, p = 0.44). Comparisons with a national control group were similar.The COPD discharge care bundle appeared to be associated with a reduction in readmission rate among hospitals using it. The significance of this is unclear because of changes to background trends in London and nationally

On certain other sets of integers

We show that if A is a subset of {1,...,N} containing no non-trivial three-term arithmetic progressions then |A|=O(N/ log^{3/4-o(1)} N).Comment: 29 pp. Corrected typos. Added definitions for some non-standard notation and remarks on lower bound

Modeling abundance using N-mixture models: the importance of considering ecological mechanisms

Predicting abundance across a species' distribution is useful for studies of ecology and biodiversity management. Modeling of survey data in relation to environmental variables can be a powerful method for extrapolating abundances across a species' distribution and, consequently, calculating total abundances and ultimately trends. Research in this area has demonstrated that models of abundance are often unstable and produce spurious estimates, and until recently our ability to remove detection error limited the development of accurate models. The N-mixture model accounts for detection and abundance simultaneously and has been a significant advance in abundance modeling. Case studies that have tested these new models have demonstrated success for some species, but doubt remains over the appropriateness of standard N-mixture models for many species. Here we develop the N-mixture model to accommodate zero-inflated data, a common occurrence in ecology, by employing zero-inflated count models. To our knowledge, this is the first application of this method to modeling count data. We use four variants of the N-mixture model (Poisson, zero-inflated Poisson, negative binomial, and zero-inflated negative binomial) to model abundance, occupancy (zero-inflated models only) and detection probability of six birds in South Australia. We assess models by their statistical fit and the ecological realism of the parameter estimates. Specifically, we assess the statistical fit with AIC and assess the ecological realism by comparing the parameter estimates with expected values derived from literature, ecological theory, and expert opinion. We demonstrate that, despite being frequently ranked the “best model” according to AIC, the negative binomial variants of the N-mixture often produce ecologically unrealistic parameter estimates. The zero-inflated Poisson variant is preferable to the negative binomial variants of the N-mixture, as it models an ecological mechanism rather than a statistical phenomenon and generates reasonable parameter estimates. Our results emphasize the need to include ecological reasoning when choosing appropriate models and highlight the dangers of modeling statistical properties of the data. We demonstrate that, to obtain ecologically realistic estimates of abundance, occupancy and detection probability, it is essential to understand the sources of variation in the data and then use this information to choose appropriate error distributions. Copyright ESA. All rights reserved

Subaru and Swift observations of V652 Herculis: resolving the photospheric pulsation

High-resolution spectroscopy with the Subaru High Dispersion Spectrograph, and Swift ultraviolet photometry are presented for the pulsating extreme helium star V652 Her. Swift provides the best relative ultraviolet photometry obtained to date, but shows no direct evidence for a shock at ultraviolet or X-ray wavelengths. Subaru has provided high spectral and high temporal resolution spectroscopy over six pulsation cycles (and eight radius minima). These data have enabled a line-by-line analysis of the entire pulsation cycle and provided a description of the pulsating photosphere as a function of optical depth. They show that the photosphere is compressed radially by a factor of at least 2 at minimum radius, that the phase of radius minimum is a function of optical depth and the pulse speed through the photosphere is between 141 and 239 km s−1 (depending how measured) and at least 10 times the local sound speed. The strong acceleration at minimum radius is demonstrated in individual line profiles; those formed deepest in the photosphere show a jump discontinuity of over 70 kms−1 on a time-scale of 150 s. The pulse speed and line profile jumps imply a shock is present at minimum radius. These empirical results provide input for hydrodynamical modelling of the pulsation and hydrodynamical plus radiative transfer modelling of the dynamical spectra

E-learning as a tool for knowledge transfer through traditional and independent study at two UK higher educational institutes: a case study

Much has been made of the advances in computer aided learning activities. Websites, virtual campus, the increased use of Web CT and chat rooms and further advances in the use of WebCT are becoming more commonplace in UK universities. This paper looks for ways of changing higher education students’ perception of the usefulness of recommended internet web sites for learning purposes, with the intention of increasing the usage rate of recommended module web-sites. The change could represent an adaptation of the existing, well-known technology to change students’ perception regarding its potentially formative role. Subsequently, the outcomes from this preliminary research could be used in order to enhance the quality of the Internet use for teaching and learning purposes