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

Teaching varies with task complexity in wild chimpanzees

Understanding social influences on how apes acquire tool behaviors can help us model the evolution of culture and technology in humans. Humans scaffold novice tool skills with diverse strategies, including the transfer of tools between individuals. Chimpanzees transfer tools, and this behavior meets criteria for teaching. However, it is unclear how task complexity relates to this form of helping. Here, we find differences between 2 wild chimpanzee populations in rate, probability, and types of tool transfer during termite gathering. Chimpanzees showed greater helping in the population where termite gathering is a more complex tool task. In wild chimpanzees, as in humans, regular and active provisioning of learning opportunities may be essential to the cultural transmission of complex skills.Cumulative culture is a transformative force in human evolution, but the social underpinnings of this capacity are debated. Identifying social influences on how chimpanzees acquire tool tasks of differing complexity may help illuminate the evolutionary origins of technology in our own lineage. Humans routinely transfer tools to novices to scaffold their skill development. While tool transfers occur in wild chimpanzees and fulfill criteria for teaching, it is unknown whether this form of helping varies between populations and across tasks. Applying standardized methods, we compared tool transfers during termite gathering by chimpanzees in the Goualougo Triangle, Republic of Congo, and in Gombe, Tanzania. At Goualougo, chimpanzees use multiple, different tool types sequentially, choose specific raw materials, and perform modifications that improve tool efficiency, which could make it challenging for novices to manufacture suitable tools. Termite gathering at Gombe involves a single tool type, fishing probes, which can be manufactured from various materials. Multiple measures indicated population differences in tool-transfer behavior. The rate of transfers and probability of transfer upon request were significantly higher at Goualougo, while resistance to transfers was significantly higher at Gombe. Active transfers of tools in which possessors moved to facilitate possession change upon request occurred only at Goualougo, where they were the most common transfer type. At Gombe, tool requests were typically refused. We suggest that these population differences in tool-transfer behavior may relate to task complexity and that active helping plays an enhanced role in the cultural transmission of complex technology in wild apes

Tool transfers are a form of teaching among chimpanzees

Teaching is a form of high-fidelity social learning that promotes human cumulative culture. Although recently documented in several nonhuman animals, teaching is rare among primates. In this study, we show that wild chimpanzees (Pan troglodytes troglodytes) in the Goualougo Triangle teach tool skills by providing learners with termite fishing probes. Tool donors experienced significant reductions in tool use and feeding, while tool recipients significantly increased their tool use and feeding after tool transfers. These transfers meet functional criteria for teaching: they occur in a learner’s presence, are costly to the teacher, and improve the learner’s performance. Donors also showed sophisticated cognitive strategies that effectively buffered them against potential costs. Teaching is predicted when less costly learning mechanisms are insufficient. Given that these chimpanzees manufacture sophisticated, brush-tipped fishing probes from specific raw materials, teaching in this population may relate to the complexity of these termite-gathering tasks

Lax pair tensors in arbitrary dimensions

A recipe is presented for obtaining Lax tensors for any n-dimensional Hamiltonian system admitting a Lax representation of dimension n. Our approach is to use the Jacobi geometry and coupling-constant metamorphosis to obtain a geometric Lax formulation. We also exploit the results to construct integrable spacetimes, satisfying the weak energy condition.Comment: 8 pages, uses IOP style files. Minor correction. Submitted to J. Phys

Devising a Resilience Rating System For Charities & The Non-Profit Sector

One of the sectoral issues that COVID has shone a light on is that whilst social investors, grant funders and sector support organisations acquire detailed data about the activities they have commissioned individually, they do not have access to a similar level of data about the wider sectors in which they are operating. �This report was written in the first 4 weeks of lockdown in 2020 and developed a framework for assessing financial resilience of Third Sector Organisations

All static spherically symmetric perfect fluid solutions of Einstein's Equations

An algorithm based on the choice of a single monotone function (subject to boundary conditions) is presented which generates all regular static spherically symmetric perfect fluid solutions of Einstein's equations. For physically relevant solutions the generating functions must be restricted by non-trivial integral-differential inequalities. Nonetheless, the algorithm is demonstrated here by the construction of an infinite number of previously unknown physically interesting exact solutions.Comment: Final form to appear in Phys Rev D. Includes a number of clarification

Gravitational Collapse of Dust with a Cosmological Constant

The recent analysis of Markovic and Shapiro on the effect of a cosmological constant on the evolution of a spherically symmetric homogeneous dust ball is extended to include the inhomogeneous and degenerate cases. The histories are shown by way of effective potential and Penrose-Carter diagrams.Comment: 2 pages, 2 figures (png), revtex. To appear in Phys. Rev.

First-principles calculation of intrinsic defect formation volumes in silicon

We present an extensive first-principles study of the pressure dependence of the formation enthalpies of all the know vacancy and self-interstitial configurations in silicon, in each charge state from -2 through +2. The neutral vacancy is found to have a formation volume that varies markedly with pressure, leading to a remarkably large negative value (-0.68 atomic volumes) for the zero-pressure formation volume of a Frenkel pair (V + I). The interaction of volume and charge was examined, leading to pressure--Fermi level stability diagrams of the defects. Finally, we quantify the anisotropic nature of the lattice relaxation around the neutral defects.Comment: 9 pages, 9 figure

New measurement of the scattering cross section of slow neutrons on liquid parahydrogen from neutron transmission

Liquid hydrogen is a dense Bose fluid whose equilibrium properties are both calculable from first principles using various theoretical approaches and of interest for the understanding of a wide range of questions in many body physics. Unfortunately, the pair correlation function $g(r)$ inferred from neutron scattering measurements of the differential cross section $d\sigma \over d\Omega$ from different measurements reported in the literature are inconsistent. We have measured the energy dependence of the total cross section and the scattering cross section for slow neutrons with energies between 0.43~meV and 16.1~meV on liquid hydrogen at 15.6~K (which is dominated by the parahydrogen component) using neutron transmission measurements on the hydrogen target of the NPDGamma collaboration at the Spallation Neutron Source at Oak Ridge National Laboratory. The relationship between the neutron transmission measurement we perform and the total cross section is unambiguous, and the energy range accesses length scales where the pair correlation function is rapidly varying. At 1~meV our measurement is a factor of 3 below the data from previous work. We present evidence that these previous measurements of the hydrogen cross section, which assumed that the equilibrium value for the ratio of orthohydrogen and parahydrogen has been reached in the target liquid, were in fact contaminated with an extra non-equilibrium component of orthohydrogen. Liquid parahydrogen is also a widely-used neutron moderator medium, and an accurate knowledge of its slow neutron cross section is essential for the design and optimization of intense slow neutron sources. We describe our measurements and compare them with previous work.Comment: Edited for submission to Physical Review