Educational Interventions to Improve Advance Care Planning Discussions, Documentation and Billing

Background/Objectives: To determine the impact of educational interventions, clinic workflow redesign, and quality improvement coaching on the frequency of advance care planning (ACP) activities for patients over the age of 65. Design: Nonrandomized before-and-after study. Setting: 13 ambulatory care clinics with 81 primary care providers in eastern and central North Carolina. Participants: Patients across 13 primary care clinics staffed by 66 physicians, 8 physician assistants and 7 family nurse practitioners. Interventions: Interprofessional, interactive ACP training for the entire interprofessional team and quality improvement project management with an emphasis on workflow redesign. Measurements: From July 2017 through June 2018—number of ACP discussions, number of written ACP documents incorporated into the electronic medical record (EMR), number of ACP encounters billed. Results: Following the interventions, healthcare providers were more than twice as likely to conduct ACP discussions with their patients. Patients were 1.4 times more likely to have an ACP document included in their electronic medical record. Providers were significantly (p < 0.05) more likely to bill for an ACP encounter in only one clinic. Conclusions: Implementing ACP education for all clinic staff, planning for workflow changes to involve the entire interprofessional team and supporting ACP activities with quality improvement coaching leads to statistically significant improvements in the frequency of ACP discussions, the number of ACP documents included in the electronic medical record and number of ACP encounters billed

Analyses and sensitivity studies on VVER-1000 using the best-estimate model Relap5/Parcs

Incorporation of fuil three-dimensional (3D) rnodels of the reactor core unto system transient codes allows for a “best-estimate” calculation of interactions between the core behavior and plant dynamics. Recent progress in computer technology has made the development of coupled system thermal-hydraulic (T-H) and neutron kinetics code systems feasible. Considerable efforts have been made in various countries and organizations in this direction. To verify the capability of the coupled codes to analyze complex transients with coupled core-plant interactions and to fully test thermal-hydraulic coupling, appropriate Light Water Reactor (L.WR) transient benchmarks were recently developed on a higher “best-estimate” level. The previous sets of transient benchmark problems addressed separately system transients (designed mainly for thermal-hydraulic (T-H) system codes with point kinetics models) and core transients (designed for T-H core boundary conditions models coupled with three-dimensional (3-D) neutron kinetics models)

Analysis of the OECD/DOE/CEA VVER1000 CT-1 benchmark using Relap5/Parcs coupled codes

Incorporation of full three-dimensional (3D) models of the reactor core into system transient codes allows better estimation of interactions between the core behavior and plant dynamics. Considerable efforts have been made in various countries and organizations to verify and validate the capability of the coupled codes technique. For these purposes appropriate Light Water Reactor (LWR) transient benchmarks based upon programmed transients performed in Nuclear Power Plants (NPP) were recently developed on a higher “best-estimate” level. The reference problem chosen for simulation in a VVER 1000 is a Main Coolant Pump (MCP) switching-on transient when the other three MCPs are in operation. This event is characterized by rapid increase in the flow through the core resulting in asymmetric coolant temperature decrease. The purpose of the work documented in this paper is three- fold: to validate the thermal-hydraulics (RELAP5) nodalization for VVER1000 analyses developed by University of Pisa, to assess the methodology developed by University of Pisa for coupling Thermal- Hydraulics (T-H) and 3-Dimensional (3-D) neutronics for VVER reactor type analyses; to contribute to the assessment of PARCS for coupled T-H/3D kinetics calculations in hexagonal geometry

Numerical Modeling of Flow and Heat Transfer During Quenching for a Postulated Loss-of-Coolant Accident

During a loss-of-coolant accident in a boiling water reactor, the liquid inventory drains from the reactor vessel and eventually the fuel bundle begins a rapid heatup when the liquid level drops below the top of the fuel and the only available cooling mechanism is a small steam flow created through coolant evaporation. Emergency core cooling liquid is either sprayed from the top of fuel bundle downward or injected from fuel bottom in an effort to remove the residual heat following the reactor shutdown and to maintain the fuel temperatures at an acceptable level as the whole system cools. Subcooled liquid injected from the top of the bundle forms a falling film that flows down the fuel rods; however this liquid is quickly evaporated by heat transfer due to the high fuel cladding temperature; the high fuel temperatures will also obstruct the liquid film from penetrating further down into the fuel bundle. The ability to predict to the film propagation is critical in determining cooling capacity and core operating limits for BWRs that rely on this cooling mode. Most thermal-hydraulic system codes used throughout the nuclear industry for accident analysis utilize a one-dimensional 2-fluid model that tracks single homogeneous liquid and vapor phases and therefore must rely on simplified models or correlations to model the complex heat transfer characteristics at the film quench front. This analysis develops an improved quenching model by incorporating a local quench front propagation model into an existing 3-field model. The new model utilizes the physical mechanism associated with the liquid film, dispersed droplets, steam flow and multidimensional conduction in the fuel rod to predict film propagation. Finally, the numerical implementation is described and compared against experimental dat

Analysis of the Peach Bottom Turbine Trip 2 Experiment by coupled Relap5-Parcs three dimensional codes

Thanks to continuous progress in computer technology, it is now possible to perform best-estimate simulations of complex scenarios in nuclear power plants. This method is carried out through the coupling of three-dimensional (3-D) neutron modeling of a reactor core into system codes. It is particularly appropriate for transients that involve strong interactions between core neutronics and reactor loop thermal hydraulics. For this purpose, the Peach Bottom boiling water reactor turbine trip test was selected to challenge the capability of such coupled codes. The test is characterized by a power excursion induced by rapid core pressurization and a self-limiting course behavior. In order to perform the closest simulation, the coupled thermal-hydraulic system code RELAP5 and 3-D neutron kinetic code PARCS were used. The obtained results are compared to those available from experimental data. Overall, the coupled code calculations globally predict the most significant observed aspects of the transient, such as the pressure wave amplitude across the core and the power course, with an acceptable agreement. However, sensitivity studies revealed that more-accurate code models should be considered in order to better match the void dynamic and the cross-section variations during transient conditions

Analysis of the VVER1000 coolant trip benchmark using the coupled RELAP5/PARCS code

Incorporation of full three-dimensional models of the reactor core into system thermalehydraulic transient codes allows better estimation of interactions between the core behavior and plant dynamics. Considerable efforts have been made in various countries and organizations to verify and validate the capability of the so-called coupled codes technique. For these purposes appropriate Light Water Reactor (LWR) transient benchmarks based upon programmed transients performed in Nuclear Power Plants (NPP) were recently developed on a higher ‘best-estimate’ level. The reference problem considered in the current framework is a Main Coolant Pump (MCP) switching-on transient in a VVER1000 NPP. This event is characterized by a positive reactivity ad- dition as consequence of the increase of the core flow. In the current study the coupled RELAP5/PARCS code is used to reproduce the considered test. Results of calculation were assessed against experimental data and also through the code-to-code comparison

A model of Early Psychological Intervention for Direct and Indirect Road Victims

Road accidents are a major emergency in Europe, and several studies investigating road trauma victims have demonstrated their serious psychological consequences and their incidence related to several serious psychological disorders (e.g., anxiety disorders, depression, psychoactive substance abuse, Acute Stress Disorder and Post-Traumatic Stress Disorder).The quality of assistance provided to the victims immediately after the event is crucial for both shortand long-term psychological consequences and can often explain the causes of post-traumatic morbidity. Based on these considerations, the paper presents a scientifically grounded early psychological intervention program that is specifically designed for road accident victims: ANIACARES.ANIACARES provides psychosocial support to road trauma victims who suffered serious injuries and/or to their relatives. This model is inspired by the most-investigated protocols related to first-aid psychology, crisis intervention, and trauma-focused psychological interventions. ANIACARES aims to reduce the possible post-traumatic psychological effects, as well as to limit the decline in the life quality of family members, and of the seriously traumatized, by providing psychological counselling and support.The program aims to support the victims during the different phases of the traumatic event to foster better emotion regulation strategies, to facilitate communication between victims and rescue personnel, to promote adherence to medical care, to promote the mourning process, to prevent the onset of post-traumatic psychopathologies, and to promote the resolution of conflicts. The validity of the model was evaluated by presenting the pre-and post-intervention results, focusing on several aspects of the individual's well-being investigated on 125 road trauma victims categorized as Direct Victims, Indirect Victims with seriously Injured family members, and Indirect Victims with a Deceased family member. Results allow to support the validity of ANIACARES; in fact, an improvement in the general conditions of psychological health and well-being of the victims has been shown and on dimensions which mood and affectivity, memory, and speech. The relevance of ANIACARES does not lie solely in developing "new" clinical techniques or procedures, but rather in structuring a specific model of psychological support and supportive intervention for a population that is too often overlooked and on which the possible outcomes are well known