Eight-step method to build the clinical content of an evidence-based care pathway: the case for COPD exacerbation

Abstract Background Optimization of the clinical care process by integration of evidence-based knowledge is one of the active components in care pathways. When studying the impact of a care pathway by using a cluster-randomized design, standardization of the care pathway intervention is crucial. This methodology paper describes the development of the clinical content of an evidence-based care pathway for in-hospital management of chronic obstructive pulmonary disease (COPD) exacerbation in the context of a cluster-randomized controlled trial (cRCT) on care pathway effectiveness. Methods The clinical content of a care pathway for COPD exacerbation was developed based on recognized process design and guideline development methods. Subsequently, based on the COPD case study, a generalized eight-step method was designed to support the development of the clinical content of an evidence-based care pathway. Results A set of 38 evidence-based key interventions and a set of 24 process and 15 outcome indicators were developed in eight different steps. Nine Belgian multidisciplinary teams piloted both the set of key interventions and indicators. The key intervention set was judged by the teams as being valid and clinically applicable. In addition, the pilot study showed that the indicators were feasible for the involved clinicians and patients. Conclusions The set of 38 key interventions and the set of process and outcome indicators were found to be appropriate for the development and standardization of the clinical content of the COPD care pathway in the context of a cRCT on pathway effectiveness. The developed eight-step method may facilitate multidisciplinary teams caring for other patient populations in designing the clinical content of their future care pathways.</p

160 MeV H−H^- Injection into the CERN PSB

The H- beam from the proposed LINAC4 will be injected into the four existing rings of the PS Booster at 160 MeV. A substantial upgrade of the injection region is required, including the modification of the beam distribution system and the construction of a new H- injection system. This paper discusses beam dynamics and hardware requirements and presents the results of optimisation studies of the injection process for different beam characteristics and scenarios. The resulting conceptual design of the injection region is presented, together with the main hardware modifications and performance specifications

Acceleration of lead ions in the CERN PS booster and the CERN PS

The new CERN Heavy Ion Accelerating Facility also requires besides a new Linac substantial modifications of existing accelerators. They are imposed by the low speed and the low intensity of the ion beam and, crucially at low energy, by the short lifetime of the partially stripped ions due to charge exchange with the atoms of the residual gas. The upgraded vacuum system hits the limits of a non-bakeable machine and consequently the acceleration had to be sped up by all means. In the Booster this led to injection and RF capture on a fast-rising magnet cycle and a new digital RF beam control system. Beam current transformers had to be replaced by new, heavily shielded ones. Other modifications include a new staircase magnet to distribute ions over the four Booster rings, lengthening of septa and kicker pulses, plus new, bakeable extraction septa and an energy stabilizing RF loop on the flat top in the CPS, and a stripper in the transfer line to the SPS

First Results for the Beam Commissioning of the CERN Multi-Turn Extraction

The Multi-Turn Extraction (MTE), a new type of extraction based on beam trapping inside stable islands in horizontal phase space, has been commissioned during the 2008 run of the CERN Proton Synchrotron. Both singleand multi-bunch beams with a total intensity up to 1.4 1013 protons have been extracted with efficiencies up to 98%. Furthermore, injection tests in the CERN Super Proton Synchrotron were performed, with the beam then accelerated and extracted to produce neutrinos for the CERN Neutrino-to-Gran Sasso experiments. The results of the extensive measurement campaign are presented and discussed in detail

An efficient application of Bayesian optimization to an industrial MDO framework for aircraft design

The multi-level, multi-disciplinary and multi-fidelity optimization framework developed at Bombardier Aviation has shown great results to explore efficient and competitive aircraft configurations. This optimization framework has been developed within the Isight software, the latter offers a set of ready-to-use optimizers. Unfortunately, the computational effort required by the Isight optimizers can be prohibitive with respect to the requirements of an industrial context. In this paper, a constrained Bayesian optimization optimizer, namely the super efficient global optimization with mixture of experts, is used to reduce the optimization computational effort. The obtained results showed significant improvements compared to two of the popular Isight optimizers. The capabilities of the tested constrained Bayesian optimization solver are demonstrated on Bombardier research aircraft configuration study cases

The CERN PS multi-turn extraction based on beam splittting in stable islands of transverse phase space: Design Report

Since 2001 considerable effort has been devoted to the study of a possible replacement of the continuous-transfer extraction mode from the PS to the SPS. Such an approach, called Multi-Turn Extraction (MTE), is based on capture of the beam inside stable islands of transverse phase space, generated by sextupoles and octupoles, thanks to a properly chosen tune variation. Both numerical simulations and measurements with beam were performed to understand the properties of this new extraction mode. The experimental study was completed at the end of 2004 and by the end of 2005 a scheme to implement this novel approach in the PS machine was defined and its performance assessed. This design report presents the outcome of the studies undertaken both in terms of technical issues as well as of resources necessary to implement the proposed scheme

Researching Complex Interventions in Health: The State of the Art : Exeter, UK. 14-15 October 2015.

Erratum to this paper available at http://hdl.handle.net/10871/23087

Effects of clinical pathways in the joint replacement: a meta-analysis

<p>Abstract</p> <p>Background</p> <p>A meta-analysis was performed to evaluate the use of clinical pathways for hip and knee joint replacements when compared with standard medical care. The impact of clinical pathways was evaluated assessing the major outcomes of in-hospital hip and knee joint replacement processes: postoperative complications, number of patients discharged at home, length of in-hospital stay and direct costs.</p> <p>Methods</p> <p>Medline, Cinahl, Embase and the Cochrane Central Register of Controlled Trials were searched. The search was performed from 1975 to 2007. Each study was assessed independently by two reviewers. The assessment of methodological quality of the included studies was based on the Jadad methodological approach and on the New Castle Ottawa Scale. Data analysis abided by the guidelines set out by The Cochrane Collaboration regarding statistical methods. Meta-analyses were performed using RevMan software, version 4.2.</p> <p>Results</p> <p>Twenty-two studies met the study inclusion criteria and were included in the meta-analysis for a total sample of 6,316 patients. The aggregate overall results showed significantly fewer patients suffering postoperative complications in the clinical pathways group when compared with the standard care group. A shorter length of stay in the clinical pathway group was also observed and lower costs during hospital stay were associated with the use of the clinical pathways. No significant differences were found in the rates of discharge to home.</p> <p>Conclusion</p> <p>The results of this meta-analysis show that clinical pathways can significantly improve the quality of care even if it is not possible to conclude that the implementation of clinical pathways is a cost-effective process, because none of the included studies analysed the cost of the development and implementation of the pathways. Based on the results we assume that pathways have impact on the organisation of care if the care process is structured in a standardised way, teams critically analyse the actual organisation of the process and the multidisciplinary team is highly involved in the re-organisation. Further studies should focus on the evaluation of pathways as complex interventions to help to understand which mechanisms within the clinical pathways can really improve the quality of care. With the need for knee and hip joint replacement on the rise, the use of clinical pathways might contribute to better quality of care and cost-effectiveness.</p

The impact of care pathways for exacerbation of Chronic Obstructive Pulmonary Disease: rationale and design of a cluster randomized controlled trial

<p>Abstract</p> <p>Background</p> <p>Hospital treatment of chronic obstructive pulmonary disease (COPD) frequently does not follow published evidences. This lack of adherence can contribute to the high morbidity, mortality and readmissions rates. The European Quality of Care Pathway (EQCP) study on acute exacerbations of COPD (NTC00962468) is undertaken to determine how care pathways (CP) as complex intervention for hospital treatment of COPD affects care variability, adherence to evidence based key interventions and clinical outcomes.</p> <p>Methods</p> <p>An international cluster Randomized Controlled Trial (cRCT) will be performed in Belgium, Italy, Ireland and Portugal. Based on the power analysis, a sample of 40 hospital teams and 398 patients will be included in the study. In the control arm of the study, usual care will be provided. The experimental teams will implement a CP as complex intervention which will include three active components: a formative evaluation of the quality and organization of care, a set of evidence based key interventions, and support on the development and implementation of the CP. The main outcome will be six-month readmission rate. As a secondary endpoint a set of clinical outcome and performance indicators (including care process evaluation and team functioning indicators) will be measured in both groups.</p> <p>Discussion</p> <p>The EQCP study is the first international cRCT on care pathways. The design of the EQCP project is both a research study and a quality improvement project and will include a realistic evaluation framework including process analysis to further understand why and when CP can really work.</p> <p>Trial Registration number</p> <p><b>NCT00962468</b></p