Determining level of care appropriateness in the patient journey from acute care to rehabilitation

Background: The selection of patients for rehabilitation, and the timing of transfer from acute care, are important clinical decisions that impact on care quality and patient flow. This paper reports utilization review data on inpatients in acute care with stroke, hip fracture or elective joint replacement, and other inpatients referred for rehabilitation. It examines reasons why acute level of care criteria are not met and explores differences in decision making between acute care and rehabilitation teams around patient appropriateness and readiness for transfer. Methods: Cohort study of patients in a large acute referral hospital in Australia followed with the InterQual utilization review tool, modified to also include reasons why utilization criteria are not met. Additional data on team decision making about appropriateness for rehabilitation, and readiness for transfer, were collected on a subset of patients. Results: There were 696 episodes of care (7189 bed days). Days meeting acute level of care criteria were 56% (stroke, hip fracture and joint replacement patients) and 33% (other patients, from the time of referral). Most inappropriate days in acute care were due to delays in processes/scheduling (45%) or being more appropriate for rehabilitation or lower level of care (30%). On the subset of patients, the acute care team and the utilization review tool deemed patients ready for rehabilitation transfer earlier than the rehabilitation team (means of 1.4, 1.3 and 4.0 days from the date of referral, respectively). From when deemed medically stable for transfer by the acute care team, 28% of patients became unstable. From when deemed stable by the rehabilitation team or utilization review, 9% and 11%, respectively, became unstable. Conclusions: A high proportion of patient days did not meet acute level of care criteria, due predominantly to inefficiencies in care processes, or to patients being more appropriate for an alternative level of care, including rehabilitation. The rehabilitation team was the most accurate in determining ongoing medical stability, but at the cost of a longer acute stay. To avoid inpatients remaining in acute care in a state of \u27terra nullius\u27, clinical models which provide rehabilitation within acute care, and more efficient movement to a rehabilitation setting, is required. Utilization review could have a decision support role in the determination of medical stability

A boundary element analysis on the influence of Krc and e/d on the performance of cyclically loaded single pile in clay

The environment prevalent in oceans necessitates the piles supporting offshore structures to be designed against lateral cyclic loading initiated by wave action. Such quasi-static load reversal induces deterioration in the strength and stiffness of the soil-pile system, introducing progressive reduction in the bearing capacity associated with increased settlement of the pile foundation. To understand the effect of lateral cyclic load on axial response of single piles in soft clay, a numerical model was previously developed and validated by the author. Using the methodology, further analysis has been carried out to investigate how the variation in relative pilesoil stiffness and eccentricity effects the degradation of axial pile capacity due to the effect of lateral cyclic load. This paper presents a brief description of the methodology, analysis and interpretations of the theoretical results obtained from the further analysis and the relevant conclusions drawn there from

The Impact of an Extreme Storm Event on the Barrier Beach of the Lefkada Lagoon, NE Ionian Sea (Greece)

The present investigation examines the characteristics of a high energy storm event, that took place on November 9-11, 2007 in the NE Ionian Sea (eastern Mediterranean), and its impact upon the barrier beach that separates the Lefkada lagoon from the open Ionian Sea. The storm event was caused by NW winds with speeds exceeding 20 m/s (40 knots), which have an annual frequency of occurrence less than 0.015%. This high energy event produced waves with >5 m significant offshore height and 9.5 s period; these waves developed on 10th November during the rapid rise of barometric pressure (~1.4 hPa/hr), which followed the barometric pressure drop from 1020.5 hPa at 06:00 (UTC) of 9th November to 1001.7 hPa at 06:00 h (UTC) of 10th November. Secondary breaking at the shoreline produced wave heights >1.5 m, associated with a surge of >0.4 m and a run-up capability of >2.4 m. The waves managed to overtop the barrier beach (elevations ~2.5 m), lowering the seaward side of the barrier beach by 10-30 cm and causing a coastline retreat of 0.9 to 2.2 m; these morphological changes correspond volumetrically to a sediment loss of approximately 8 m3/m of coastline length from the sub-aerial part of the beach. During the last three decades a significant change in the frequency of occurrence and direction (from S-SW-W to N-NW-NE) of severe storms with wind speeds exceeding 40 knots has been recorded, affecting the sediment transport pattern and contributing to the erosion of the north beaches of Lefkada

Psychosocial drivers for change: understanding and promoting stakeholder engagement in local adaptation to climate change in three European Mediterranean case studies

Stakeholder engagement in the processes of planning local adaptation to climate change faces many challenges. The goal of this work was to explore whether or not the intention of engaging could be understood (Study 1) and promoted (Study 2), by using an extension of the theory of planned behaviour. In Study 1, stakeholders from three European Mediterranean case studies were surveyed: Baixo Vouga Lagunar (Portugal), SCOT Provence Méditerranée (France), and the island of Crete (Greece) (N = 115). Stakeholders' intention of engaging was significantly predicted by subjective norm (which was predicted by injunctive normative beliefs towards policy-makers and stakeholders) and by perceived behavioural control (which was predicted by knowledge of policy and instruments). Study 2 was conducted in the Baixo Vouga Lagunar case study and consisted of a two-workshop intervention where issues on local and regional adaptation, policies, and engagement were presented and discussed. A within-participants comparison of initial survey results with results following the workshops (NT1 = 12, NT2 = 15, NT3 = 12) indicated that these were successful in increasing stakeholders' intention of engaging. This increase was paired with a) an increase in injunctive normative beliefs towards policy-makers and consequently in subjective norm, and to b) a decrease in perceived complexity of planning local adaptation and an increase in knowledge regarding adaptation to climate change.info:eu-repo/semantics/acceptedVersio

CASES-99: a comprehensive investigation of the stable nocturnal boundary layer

The Cooperative Atmosphere-Surface Exchange Study—1999 (CASES-99) refers to a field experiment carried out in southeast Kansas during October 1999 and the subsequent program of investigation. Comprehensive data, primarily taken during the nighttime but typically including the evening and morning transition, supports data analyses, theoretical studies, and state-of-the-art numerical modeling in a concerted effort by participants to investigate four areas of scientific interest. The choice of these scientific topics is motivated by both the need to delineate physical processes that characterize the stable boundary layer, which are as yet not clearly understood, and the specific scientific goals of the investigators. Each of the scientific goals should be largely achievable with the measurements taken, as is shown with preliminary analysis within the scope of three of the four scientific goals. Underlying this effort is the fundamental motivation to eliminate deficiencies in surface layer and turbulent diffusion parameterizations in atmospheric models, particularly where the Richardson number exceeds 0.25. This extensive nocturnal boundary layer (NBL) dataset is available to the scientific community at large, and the CASES-99 participants encourage all interested parties to utilize it.Carmen Nappo acknowledges the support of the U.S. Army Research Laboratory under Grant MIPROB-NOAA007. JS and SB acknowledge the support of Army Research Office Grant DAAD 1999- 1-0320, National Science Foundation Grant ATM-9906637. JC and ET acknowledge the Spanish Commission for Science and Technology through Projects CLI97-0343 and CLI99-1326- E

Revisiting the Local Scaling Hypothesis in Stably Stratified Atmospheric Boundary Layer Turbulence: an Integration of Field and Laboratory Measurements with Large-eddy Simulations

The `local scaling' hypothesis, first introduced by Nieuwstadt two decades ago, describes the turbulence structure of stable boundary layers in a very succinct way and is an integral part of numerous local closure-based numerical weather prediction models. However, the validity of this hypothesis under very stable conditions is a subject of on-going debate. In this work, we attempt to address this controversial issue by performing extensive analyses of turbulence data from several field campaigns, wind-tunnel experiments and large-eddy simulations. Wide range of stabilities, diverse field conditions and a comprehensive set of turbulence statistics make this study distinct