Optimising acute stroke pathways through flexible use of bed capacity: a computer modelling study

BACKGROUND: Optimising capacity along clinical pathways is essential to avoid severe hospital pressure and help ensure best patient outcomes and financial sustainability. Yet, typical approaches, using only average arrival rate and average lengths of stay, are known to underestimate the number of beds required. This study investigates the extent to which averages-based estimates can be complemented by a robust assessment of additional ‘flex capacity’ requirements, to be used at times of peak demand. METHODS: The setting was a major one million resident healthcare system in England, moving towards a centralised stroke pathway. A computer simulation was developed for modelling patient flow along the proposed stroke pathway, accounting for variability in patient arrivals, lengths of stay, and the time taken for transfer processes. The primary outcome measure was flex capacity utilisation over the simulation period. RESULTS: For the hyper-acute, acute, and rehabilitation units respectively, flex capacities of 45%, 45%, and 36% above the averages-based calculation would be required to ensure that only 1% of stroke presentations find the hyper-acute unit full and have to wait. For each unit some amount of flex capacity would be required approximately 30%, 20%, and 18% of the time respectively. CONCLUSIONS: This study demonstrates the importance of appropriately capturing variability within capacity plans, and provides a practical and economical approach which can complement commonly-used averages-based methods. Results of this study have directly informed the healthcare system’s new configuration of stroke services. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12913-022-08433-0

A Mixed Methods Small Pilot Study to Describe the Effects of Upper Limb Training Using a Virtual Reality Gaming System in People with Chronic Stroke

Introduction. This small pilot study aimed to examine the feasibility of an upper limb rehabilitation system (the YouGrabber) in a community rehabilitation centre, qualitatively explore participant experiences, and describe changes after using it. Methods and Material. Chronic stroke participants attending a community rehabilitation centre in the UK were randomised to either a YouGrabber or a gym group and completed 18 training sessions over 12 weeks. The motor activity log, box and block, and fatigue severity score were administered by a blinded assessor before and after the intervention. Semistructured interviews were used to ascertain participants’ views about using the YouGrabber. Results. Twelve participants (6 females) with chronic stroke were recruited. All adhered to the intervention. There were no adverse events, dropouts, or withdrawal. There were no significant differences between the YouGrabber and gym groups although there were significant within group improvements on the motor activity log (median change: 0.59, range: 0.2–1.25; ) within the YouGrabber group. Participants reported that the YouGrabber was motivational but they expressed frustration with technical challenges. Conclusions. The YouGrabber appeared practical and may improve upper limb activities in people several months after stroke. Future work could examine cognition, cost effectiveness, and different training intensities

Contracting with General Dental Services: a mixed-methods study on factors influencing responses to contracts in English general dental practice

Background: Independent contractor status of NHS general dental practitioners (GDPs) and general medical practitioners (GMPs) has meant that both groups have commercial as well as professional identities. Their relationship with the state is governed by a NHS contract, the terms of which have been the focus of much negotiation and struggle in recent years. Previous study of dental contracting has taken a classical economics perspective, viewing practitioners’ behaviour as a fully rational search for contract loopholes. We apply institutional theory to this context for the first time, where individuals’ behaviour is understood as being influenced by wider institutional forces such as growing consumer demands, commercial pressures and challenges to medical professionalism. Practitioners hold values and beliefs, and carry out routines and practices which are consistent with the field’s institutional logics. By identifying institutional logics in the dental practice organisational field, we expose where tensions exist, helping to explain why contracting appears as a continual cycle of reform and resistance. Aims: To identify the factors which facilitate and hinder the use of contractual processes to manage and strategically develop General Dental Services, using a comparison with medical practice to highlight factors which are particular to NHS dental practice. Methods: Following a systematic review of health-care contracting theory and interviews with stakeholders, we undertook case studies of 16 dental and six medical practices. Case study data collection involved interviews, observation and documentary evidence; 120 interviews were undertaken in all. We tested and refined our findings using a questionnaire to GDPs and further interviews with commissioners. Results: We found that, for all three sets of actors (GDPs, GMPs, commissioners), multiple logics exist. These were interacting and sometimes in competition. We found an emergent logic of population health managerialism in dental practice, which is less compatible than the other dental practice logics of ownership responsibility, professional clinical values and entrepreneurialism. This was in contrast to medical practice, where we found a more ready acceptance of external accountability and notions of the delivery of ‘cost-effective’ care. Our quantitative work enabled us to refine and test our conceptualisations of dental practice logics. We identified that population health managerialism comprised both a logic of managerialism and a public goods logic, and that practitioners might be resistant to one and not the other. We also linked individual practitioners’ behaviour to wider institutional forces by showing that logics were predictive of responses to NHS dental contracts at the dental chair-side (the micro level), as well as predictive of approaches to wider contractual relationships with commissioners (the macro level) . Conclusions: Responses to contracts can be shaped by environmental forces and not just determined at the level of the individual. In NHS medical practice, goals are more closely aligned with commissioning goals than in general dental practice. The optimal contractual agreement between GDPs and commissioners, therefore, will be one which aims at the ‘satisfactory’ rather than the ‘ideal’; and a ‘successful’ NHS dental contract is likely to be one where neither party promotes its self-interest above the other. Future work on opportunism in health care should widen its focus beyond the self-interest of providers and look at the contribution of contextual factors such as the relationship between the government and professional bodies, the role of the media, and providers’ social and professional networks. Funding: The National Institute for Health Research Health Services and Delivery Research programme

Use of mobile phones and text messaging to decrease the turnaround time for early infant HIV diagnosis and notification in rural Zambia: An observational study

Background: Early infant diagnosis of HIV infection is challenging in rural sub-Saharan Africa as blood samples are sent to central laboratories for HIV DNA testing, leading to delays in diagnosis and treatment initiation. Simple technologies to rapidly deliver results to clinics and notify mothers of test results would decrease many of these delays. The feasibility of using mobil

Climate Change Science Program Overview and Management

This program identifies the following criteria of interest: scientific or technical quality; relevance to reducing uncertainties and improving decision support tools; track record of consistently good past performance and identified metrics for evaluating future progress; and cost and value

Spectroscopic confirmation of hydrogen alpha-selected satellite galaxies

We present a spectroscopic test confirming the potential of narrow-band optical imaging as a method for detecting star-forming satellites around nearby galaxies. To date the efficiency of such methods, and particularly the fraction of false detections resulting from its use, has not been tested. In this paper we use optical spectroscopy to verify the nature of objects that are apparently emission-line satellites, taken from imaging presented elsewhere. Observations of 12 probable satellites around 11 host galaxies are presented and used to compare the recession velocities of the host and satellite. This test confirms, in all cases, that there is genuine line emission, that the detected line is hydrogen alpha, and that the satellites have similar recession velocities to their hosts with a maximum difference of ~ 250 km/s, consistent with their being gravitationally bound companions. We conclude that the spectroscopy has confirmed that narrow-band imaging through H alpha filters is a reliable method for detecting genuine, star-forming satellites with low contamination from galaxies seen in projection along the line-of-sight.Comment: Accepted for publication in MNRAS,8 pages,4 figures, 2 table

Critical materials for infrastructure: local vs global properties

Introducing new technologies into infrastructure (wind turbines, electric vehicles, low-carbon materials and so on) often demands materials that are ‘critical’; their supply is likely to be disrupted owing to limited reserves, geopolitical instability, environmental issues and/or increasing demand. Non-critical materials may become critical if introduced into infrastructure, owing to its gigatonne scale. This potentially poses significant risk to the development of low-carbon infrastructure. Analysis of this risk has previously overlooked the relationship between the ‘local properties’ that determine the selection of a technology and the overall vulnerability of the system, a global property. Treating materials or components as elements having fixed properties overlooks optima within the local–global variable space that could be exploited to minimise vulnerability while maximising performance. In this study, a framework for such analysis is presented along with a preliminary measure of relative materials criticality by way of a case study (a wind turbine generator). Although introduction of critical materials (in this case, rare earth metals) enhances technical performance by up to an order of magnitude, the associated increase in criticality may be two or three orders of magnitude. Analysis at the materials and component levels produces different results; design decisions should be based on analysis at several levels

US National Climate Assessment (NCA) Scenarios for Assessing Our Climate Future: Issues and Methodological Perspectives Background Whitepaper for Participants

This whitepaper is intended to provide a starting point for discussion at a workshop for the National Climate Assessment (NCA) that focuses on the use and development of scenarios. The paper will provide background needed by participants in the workshop in order to review options for developing and using scenarios in NCA. The paper briefly defines key terms and establishes a conceptual framework for developing consistent scenarios across different end uses and spatial scales. It reviews uses of scenarios in past U.S. national assessments and identifies potential users of and needs for scenarios for both the report scheduled for release in June 2013 and to support an ongoing distributed assessment process in sectors and regions around the country. Because scenarios prepared for the NCA will need to leverage existing research, the paper takes account of recent scientific advances and activities that could provide needed inputs. Finally, it considers potential approaches for providing methods, data, and other tools for assessment participants. We note that the term 'scenarios' has many meanings. An important goal of the whitepaper (and portions of the workshop agenda) is pedagogical (i.e., to compare different meanings and uses of the term and make assessment participants aware of the need to be explicit about types and uses of scenarios). In climate change research, scenarios have been used to establish bounds for future climate conditions and resulting effects on human and natural systems, given a defined level of greenhouse gas emissions. This quasi-predictive use contrasts with the way decision analysts typically use scenarios (i.e., to consider how robust alternative decisions or strategies may be to variation in key aspects of the future that are uncertain). As will be discussed, in climate change research and assessment, scenarios describe a range of aspects of the future, including major driving forces (both human activities and natural processes), changes in climate and related environmental conditions (e.g., sea level), and evolution of societal capability to respond to climate change. This wide range of scenarios is needed because the implications of climate change for the environment and society depend not only on changes in climate themselves, but also on human responses. This degree of breadth introduces and number of challenges for communication and research