The impact of delayed transfers of care on emergency departments: common sense arguments, evidence and confounding

This is the final version. Available on open access from BMJ Publishing Group via the DOI in this recordData availability statement: All data and code required to reproduce this study are available at http://doi.org/10.5281/zenodo.3523179Objectives There have been claims that Delayed Transfers of Care (DTOCs) of inpatients to home or a less acute setting are related to Emergency Department (ED) crowding. In particular DTOCs were associated with breaches of the UK 4-hour waiting time target in a previously published analysis. However, the analysis has major limitations by not adjusting for the longitudinal trend of the data. The aim of this work is to investigate whether the proposition that DTOCs impact the 4-hour target requires further research. Method Estimation of an association between two or more variables that are measured over time requires specialised statistical methods. In this study, we performed two separate analyses. First, we created two sets of artificial data with no correlation. We then added an upward trend over time and again assessed for correlation. Second, we reproduced the simple linear regression of the original study using NHS England open data of English trusts between 2010 and 2016, assessing correlation of numbers of DTOCs and ED breaches of the 4-hour target. We then reanalysed the same data using standard time series methods to remove the trend before estimating an association. Results After introducing upward trends into the uncorrelated artificial data the correlation between the two data sets increased (R2=0.00 to 0.51 respectively). We found strong evidence of longitudinal trends within the NHS data of ED breaches and DTOCs. After removal of the trends the R2 reduced from 0.50 to 0.01. Conclusion Our reanalysis found weak correlation between numbers of DTOCs and ED 4-hour target breaches. Our study does not indicate that there is no relationship between 4-hour target and DTOCs, it highlights that statistically robust evidence for this relationship does not currently exist. Further work is required to understand the relationship between breaches of the 4-hour target and numbers of DTOCs.National Institute for Health Research (NIHR

Lateral phase separation of confined membranes

We consider membranes interacting via short, intermediate and long stickers. The effects of the intermediate stickers on the lateral phase separation of the membranes are studied via mean-field approximation. The critical potential depth of the stickers increases in the presence of the intermediate sticker. The lateral phase separation of the membrane thus suppressed by the intermediate stickers. Considering membranes interacting with short and long stickers, the effect of confinement on the phase behavior of the membranes is also investigated analytically

Towards generic modelling of hospital wards: Reuse and redevelopment of simple models

This is the final version. Available on open access from Taylor & Francis via the DOI in this recordGeneric simulation models are designed to enable model reuse. We argue that there are two weaknesses within the generic simulation modelling literature. Firstly, that generic models sacrifice the relative simplicity of a bespoke simulation model for flexibility. Secondly, that generic models are published in conceptual form only. If researchers cannot access computer implementation of models, then there is little incentive or benefit to recode one over coding a simpler bespoke simulation model. We introduce an incremental approach to generic modelling in discrete-event simulation. We develop an archetype setting-specific generic model of a hospital ward. The archetype model is first developed and applied in a rehabilitation ward setting. Then a second team applies the model in a specialised intensive care setting. We report the successes, obstacles and redevelopment needed for reuse of the generic model along with how the results of these studies were used to inform healthcare delivery.National Institute for Health Research (NIHR

A mixed methods study of the impact of consultant overnight working in an English Emergency Department

This is the final version. Available on open access from BMJ Publishing Group via the DOI in this recordBackground There is a growing expectation that consultant-level doctors should be present within an ED overnight. However, there is a lack of robust evidence substantiating the impact on patient waiting times, safety or the workforce. Objectives To evaluate the impact of consultant-level doctors overnight working in ED in a large university hospital. Methods We conducted a controlled interrupted time series analysis to study ED waiting times before and after the introduction of consultant night working. Adverse event reports (AER) were used as a surrogate for patient safety. We conducted interviews with medical and nursing staff to explore attitudes to night work. Results The reduction seen in average time in department relative to the day, following the introduction of consultant was non-significant ('12 min; 95% CI '28 to 4, p=0.148). Analysis of hourly arrivals and departures indicated that overnight work was inherited from the day. There were three (0.9%) moderate and 0 severe AERs in 1 year. The workforce reported that night working had a negative impact on sleep patterns, performance and well-being and there were mixed views about the benefits of consultant night presence. Additional time off during the day acted as compensation for night work but resulted in reduced contact with ED teams. Conclusions Our single-site study was unable to demonstrate a clinically important impact of consultant night working on total time patients spend in the department. Our analysis suggests there may be more potential to reduce total time in department during the day, at our study site. Negative impacts on well-being, and likely resistance to consultant night working should not be ignored. Further studies of night working are recommended to substantiate our results.National Institute for Health Research (NIHR)University Hospital Southampto

A Practical Approach to Subset Selection for Multi-objective Optimization via Simulation

This is the author accepted manuscript. The final version is available from ACM via the DOI in this recordWe describe a practical two-stage algorithm, BootComp, for multi-objective optimization via simulation. Our algorithm finds a subset of good designs that a decision-maker can compare to identify the one that works best when considering all aspects of the system, including those that cannot be modeled. BootComp is designed to be straightforward to implement by a practitioner with basic statistical knowledge in a simulation package that does not support sequential ranking and selection. These requirements restrict us to a two-stage procedure that works with any distributions of the outputs and allows for the use of common random numbers. Comparisons with sequential ranking and selection methods suggest that it performs well, and we also demonstrate its use analyzing a real simulation aiming to determine the optimal ward configuration for a UK hospital.National Institute for Health Research (NIHR

High-Density Espalier Trained Mangoes Make Better Use of Light

Mango productivity and fruit quality in Australia can be improved through transforming low-density plantings to high-density plantings and intensive training systems. Several planting density and training systems were established in Australia to investigate optimizing light interception and distribution, yield and fruit quality, and to reduce tree vigor and biennial bearing through the manipulation of canopy architecture. In this research, we studied light relations and yield in conventional low-density commercial orchards of different ages and investigated light relations and yield of ‘National Mango Breeding Program NMBP1243’, ‘Keitt’ and ‘Calypso’ grafted to ‘Kensington Pride (KP)’ rootstock in a replicated experiment. Trees were trained to five planting systems: high-density espalier and conventional, medium-density single leader and conventional, and low-density conventional. Our study in commercial orchards showed that maximum yield was ~16,000 kg/ha when light interception reached ~49% and declined at higher levels of light interception. In the high-density intensive training systems, we found that light interception increased with canopy volume, with high-density espalier training systems intercepting more available light compared to medium-density training systems and low-density conventional trees. Yield/ha increased to ~50,000 kg/ha in espalier training systems when light interception was ~40%. Light interception, canopy volume and yield/ha varied between varieties

Fostering the next generation of reviewers in New Zealand ecology

Conservation Biolog

Indirect interactions of membrane-adsorbed cylinders

Biological and biomimetic membranes often contain aggregates of embedded or adsorbed macromolecules. In this article, the indirect interactions of cylindrical objects adhering to a planar membrane are considered theoretically. The adhesion of the cylinders causes a local perturbation of the equilibrium membrane shape, which leads to membrane-mediated interactions. For a planar membrane under lateral tension, the interaction is repulsive for a pair of cylinders adhering to the same side of the membrane, and attractive for cylinders adhering at opposite membrane sides. For a membrane in an external harmonic potential, the interaction of adsorbed cylinders is always attractive and increases if forces perpendicular to the membrane act on the cylinders.Comment: 9 pages, 8 figures; typos correcte

Can clinical audits be enhanced by pathway simulation and machine learning? An example from the acute stroke pathway

OBJECTIVE: To evaluate the application of clinical pathway simulation in machine learning, using clinical audit data, in order to identify key drivers for improving use and speed of thrombolysis at individual hospitals