Using discrete event simulation to improve the patient care process in the emergency department of a rural Kentucky hospital.

The patient care process of a rural Kentucky hospital is a complex process that must be flexible in order to deal with a large variety of patient needs and a fluctuating patient volume where all patients are unscheduled. A simulation model of an average month in the emergency department was built using the Arena Simulation package. Methods for creating a simulation using Arena are included in this work. Statistics were generated from a number of different sources to create an accurate representation of the model. The Hospital reporting shows a need to improve on two quality measures being tracked, the length of time a patient is in the emergency department from entry to completion of care, and the number of patients who leave without being seen by the physician (most often due to the length of their waiting room time prior to the initiation of care). Due to the complex nature of the emergency department and its impact by other departments of the Hospital as well as outside factors such as patient demand, the ability to quantify an expected gain from a change to the facility or to a process can be difficult to establish. A simulation model will allow for experiments on the system to be created and observed, thus enabling the Hospital to identify the best opportunities for improvement. Experiments included in this work show changes to the emergency department facility by adding an additional patient treatment bed, and changing a policy regarding transfer of a patient from the emergency department to inpatient care in the Hospital. Both experiments show improvement in quality measures, with reduced waiting room times, fewer patients who leave without being seen by the physician, and an overall reduction in the length of stay from entry to completion of care in the ED. In the creation of the simulation model, an objective was to develop a model that could be used to guide decision through its flexibility and statistical reliability. The model can be used to test a variety of physical or procedural changes to the emergency department, as well as to test to the impacts of increased patient volume

A comparison of different work: rest ratios in a high intensity interval-training programme; the effect on performance and health parameters

Background It is well documented that high intensity interval training (HIIT) is a time efficient and effective method of training to improve exercise performance. However, there are a wide range of intervention protocols used in both research and applied fields, making comparison of data difficult. Previous work from our laboratory (Lloyd-Jones et al., under review) suggested that the work:rest ratio used during this type of training may be important in determining adaptations, and in selecting the most efficient training approach, although this a poorly understood and often neglected consideration. Therefore the aim of this study is to compare different work:rest ratio, all using a 6 second sprint but with either a 1:8, 1:10 or 1:12 work:rest ratio. Methods 35 active male and females (age: 24 ± 4 years, height: 1.77 ± 0.09m, body mass: 74.7 ± 12.9kg, body fat: 16.8 ± 6.1%, height, body mass, body fat) initially completed a VO2max step test, followed at least 24hrs later by a thigh occlusion test whilst wearing near-infrared spectroscopy over the vastus lateralis muscle, and a 10km cycling time trial. Participants then completed 6 sessions of HIIT on a cycle ergometer split over 2 weeks, consisting of 10x6 sec sprints with either 48sec rest (1:8 group), 60sec rest (1:10 group) or 72sec rest (1:12 group), and compared with a control group in a randomised controlled trial. Peak and average power output were calculated for each sprint session and peak power calculated for each individual sprint. Results There was no significant change in VO2max following 2 weeks of training in any group, or 10km time trial performance (1:8: pre: 780 ± 258sec post: 751 ± 270sec, 1:10 pre: 572 ± 138sec post: 563 ± 134sec, 1:12: pre: 641 ± 100sec post: 615 ± 94sec, Con: pre: 716 ± 207sec post: 761 ± 229sec). Peak power output increased significantly in the 1:8 group (1038 ± 330 -1095 ± 357 watts), 1:10 group (1092 ± 282 - 1148 ± 286 watts) and 1:12 group (1043 ± 201 - 1097 ± 226 watts). The average range of the change in power over the 4 training session, for all the six sprint sessions for the 1:8 group was 62watts, the 1:10 group was 44watts and the 1:12 group was 45watts. There was no change in muscle oxygen kinetic data in any group following 2 weeks of HIIT as assessed by thigh occlusion. Conclusion The performance improvements in 10km time trial performance were largest in the 1:8 and 1:12 groups. It is possible that there was insufficient recovery time in the 1:8 condition, resulting in metabolic stress to the cardiovascular system, and that adaptations in the 1:12 condition may be a consequence of repeatedly achieving peak power output, facilitated by a sufficient recovery period. It is therefore possible that adaptations following HIIT can be elicited from different stimuli, and this should be considered in future research and practice

Governing the constructs of life: what constitutes ‘good’ governance?

This thesis explores contrasting perspectives on what constitutes 'good governance' for human embryonic stem cell (hESC) research. It asks whether there are systematic differences between perspectives of UK and US policy actors and what kinds of patterns are discernible. Biomedical technologies like hESCs generate complex interactions between public values, institutional interests, societal expectations and technological uncertainties. These pose serious governance challenges. Under such conditions, diverse aspects and implications of risk, ambiguity and uncertainty come into focus. We need appraisal processes that address these issues by combining quantitative and qualitative dimensions to 'open up' divergent governance framings. The research framework employed here uses and further develops one such elicitation and analysis process called Multicriteria Mapping (MCM). MCM combines qualitative sensitivity with quantitative precision, while also aiding transparency and reflexivity in documenting and understanding diverse stakeholder perspectives. We therefore address 'good' governance both as an analytical subject and as a rationale for testing a novel form of appraisal. The analysis discerns systematic patterns in perspectives on good governance across national contexts and between stakeholders, identifying several points of convergence and divergence. We examine underlying rationales behind individual perspectives, obtaining empirical support for recent theoretical arguments concerning technology appraisal and democratic deliberation. We find national policy literatures make greater use of moral and ethical language to frame governance challenges, by comparison with stakeholders' emphasis on institutional and socio-political factors. This suggests a more critical and cautious stance is needed towards the legitimatory language of 'bioethics' in policy making. Finally, we explore some of the normative implications for governance of culturally sensitive and scientifically uncertain issues. By providing reflexive explanations of factors influencing perspectives of policy actors, this thesis makes a number of interlinked theoretical, methodological, empirical and normative contributions to understanding of how good governance of biomedical technologies is and should be conducted

The progress of reclamation on the Bagshot Series between the Loddon and the Wey

An examination has been made, from a geographer's standpoint, of the progress of the reclamation of rough wasteland on the Bagshot Series (between the Loddon and Wey) for farming, horticulture and forestry. Soil and groundwater conditions on the Bagshots outcrop present problems for both cultivation and afforestation. Difficulties have been accentuated by the deterioration of the surface of the wastes due to interference with the vegetation, this resulting in damaging erosion and podsolisation. The region when first occupied by man was one of deciduous woodland. Degradation to heath and bog began in pre-historic times. Many parts of the outcrop were being cultivated by the late eleventh century; and considerable expansion occurred up to the mid-fourteenth century, much woodland still remaining during this phase. The distribution of the settlement and farmland of that time can be correlated with surface conditions; and the sporadic reclamation that followed until the mid-eighteenth century was largely confined within the same geographical framework. Meanwhile the wastes continued to deteriorate, degraded conditions reaching their maximum extent during the seventeenth and eighteenth centuries when the unenclosed ground on the outcrop was virtually all heath and bog. Between the late eighteenth and mid-nineteenth centuries progress was accelerated and great advances were made outside the earlier framework in response to powerful economic and social stimuli, circumstances then favouring afforestation with conifers. Since then the emerging pattern of farmland and plantations has been disturbed by military interests and much obliterated by residential development, these meeting little opposition owing to the low agricultural potential of the area. The wastes meanwhile have become in places recolonised with trees, both deciduous hardwoods and conifers. Those not reserved to the War Department are now mostly being retained in their "wild" state as public open spaces. Further reclamation seems unlikely in the foreseeable future.<p

Voices from the Holocaust, Remembered: Selected Works for Cello

During the Holocaust, many prominent Jewish composers’ lives and careers were cut short in their prime. Their music was banned and they had to abandon their homes and emigrate in order to survive. Tragically, many were shipped off to concentration camps where they were murdered. These composers were stripped of all possible advantages. As a result, their music often fell into obscurity. I chose to explore the lives and works of six of these composers: Hans Gál, Hans Krása, Gideon Klein, Erwin Schulhoff, James Simon, and Alexander Zemlinsky. Through my dissertation, I hope to promote their compelling music and bring some measure of justice to the tragedy of lives and careers cut short by the Holocaust

Some Implicit Presuppositions of Typical Writings in the Field of American Intellectual History

This paper reports a study made of some of the implicit presuppositions contained in the following materials: The Federalist, papers 10 and 51 by Madison, selections from de Tocqueville's Democracy in America; Emerson's "The American Scholar"; Melville's "Bartleby the Scrivener"; "Washington as Commander in Chief” in Bancroft's History of the United States; and "A Small Group of Men Hold in their hands the Business of this Country," a Senate speech by Robert M. LaFollette, Fifteen students at the Claremont Graduate School, who had taken a course in which these materials were studied, rated them on seven scales, or "dimensions, " each of which represents one of a contrasting pair of implicit presuppositions which we have identified and defined. At 19 of the 42 choice points at which decisions had to be made (six selections on seven dimensions) the ratings proved to be significant at p < .05 level. These results thus expand the "scope" of our set of implicit presuppositions to include new materials not previously investigated. In short, it has been shown that readers who are guided by our definitions are able to agree on some of the implicit assumptions contained in a representative sample of writings in the field of American intellectual history

Some Implicit Presuppositions Involved in the Disagreement over the DNA Guidelines

This paper is one of a series reporting studies we have made of differences in implicit presuppositions and of how such differences affect the ways people reason. In the study reported here 26 students (14 at Caltech; 12 at Claremont) read and rated four letters which had appeared in the correspondence columns of Science. Two of the letters defended the guidelines governing DNA research; two criticized them. The students rated the letters on six scales, or "dimensions," each of which represents a contrasting pair of implicit presuppositions, which we have identified and defined. For two of the six dimensions all four of the letters were rated in the predicted direction, and all are statistically significant. On a third dimension all four of the letters were rated in the predicted direction, but only three of the four are statistically significant. For the other three dimensions there was no consistent pattern, though some of the results on some of the dimensions were in the predicted direction and are statistically significant. Thus this study shows that in certain important respects the presuppositions of the proponents and the presupposition of the opponents of the guidelines are not only different but diametrically opposed