Climate change and variability, energy and disaster management: produced risks without produced solutions: rethinking the approach

Accelerated climate change and increasing climate variability is the single largest threat to the international goals of sustainable development, the Millennium Development Goals (MDGs) and disaster risk reduction. Global discourses recognise the need for effective and sustainable responses tso produced climate risks. The risk types likely to occur are known, but only in broad terms - their scale, severity, longevity and frequency are not known. The challenge for policymakers is developing an effective framework within which sustainable responses can be formulated. To address the problems of produced risks a comprehensive approach to risk management is necessary. The mechanisms within the climate change, sustainable development and disaster risk reduction discourses are not sufficiently effective or integrated to respond to this challenge. Fundamental reform to current modes of risk reduction is needed, but this can only be achieved through a shift in the dominant perspective on formulating sustainable responses. This requires a shift to an enabling policy framework that encourages bottom-up resilient responses. Resilience is argued as a tool for policy development that can enhance adaptive capacity to current climate risks and shape energy policy to respond to mitigate future climate risks

'Spaces to speak' of sour milk : exploring African-Caribbean-British women's activism and agency on childhood sexual abuse from the 1980s to the present day

The aim of this research study is to add the voices of African- Caribbean British female victim-survivors of childhood sexual abuse (CSA) to existing knowledge(s) on childhood sexual victimization. In so doing the study will examine whether racialisation, racism and cultural identity and cultural factors have had any bearing on African Caribbean British women’s 'space to speak' of childhood sexual abuse. The study also explores Black British feminist activism on CSA from the late 1970s- mid 1980s in order to further explore the issue of spaces to speak. The thesis presents findings from 5 in-depth interviews with Black British feminists (Experts); a partial content analysis of British feminist periodicals from 1980s onward; 7 in-depth interviews with African-Caribbean British victim-survivors of CSA and a survey examining Black, Asian and Minority, Ethnic service provision (BAME) in 13 Rape Crisis Centre’s in England and Scotland

Service user experience of the Norfolk youth service

Purpose: There is an international drive to improve mental health services for young people. This study aims to investigate service user experience of a youth mental health service in Norfolk, UK. In addition to suggesting improvements to this service, recommendations are made for the development of youth mental health services in general. Design/methodology/approach: A mixed-methods approach was used. Quantitative data from satisfaction questionnaires were analysed using descriptive statistics and compared between two time points. A semi-structured interview was used to generate qualitative data. Thematic analysis was used to identify themes in the interview transcripts and triangulation was used to synthesise quantitative and qualitative data. Findings: Service users appeared satisfied with the service. Significant improvements in satisfaction were found between two time points. Qualitative analysis identified three main themes that were important to service users, including support, information and personhood. Practical implications: Recommendations for the development of youth mental health services are provided. Although these are based on findings from the Norfolk youth service, they are likely to apply to other mental health services for young people. Originality/value: Mental health care for young people requires significant improvement. The Norfolk youth service is one of the first services of its kind in the UK. The findings from this study might be helpful to consider in the development of youth mental health services across the world

The effect of nurse initiated paracetamol on emergency department patients with pain from low acuity injury

Early identification and management of pain was identified at the commencement of this study as a key area requiring research in emergency departments. Prolonged waiting times for analgesia especially, was highlighted in the National Institute of Clinical Studies emergency department collaborative in 2003. Many barriers exist for a patient to receive analgesia. In Western Australia this is compounded by the legislation which restricts prescribing rights for nurses. Three considerations guided the development of the research project. Firstly, the patient has initial contact with the emergency department from the nurse at triage. Secondly, paracetamol was recognised as a potentially effective analgesic that a nurse could administer in the study hospital without having to first seek a medical prescription. Finally, the group of patients who waited the longest for any pain relief were those with low acuity presentations placed in the waiting room until medical review. Within this group, patients with musculoskeletal injury to limbs were identified as the most likely to gain benefit from determining the effectiveness of paracetamol as a means of pain relief for their injury. No literature was identified at the commencement of the study which examined the effectiveness of paracetamol administered at triage by nurses for patients with recent musculoskeletal injury

Quality development framework for extended services

The Quality Development Framework (QDF) is a flexible self-evaluation tool which supports review and self-assessment, planning and quality assurance. It is a framework for schools, Children’s Centres and multi-agency partners working as Consortia to deliver Extended Services, which recognises the complex and developmental nature of this process. Engagement with the QDF will contribute to the completion of Schools and Children’s Centres’ Self Evaluations Forms and provide an evidence base to support other Self-Evaluation processes and Quality Assurance systems

Prioritising pre-hospital outcome measures with a multi-stakeholder group: a consensus methods study

Context: A consensus event to discuss and prioritise ambulance service care outcome measures was held with 43 participants from a range of professional backgrounds including Commissioners; Policy makers; clinicians; managers; academics and patient and public representatives. Problem: Ambulance services in England manage 8 million emergency calls per years and treat 6.5 million people. Services are currently unable to ascertain whether the care they provide is safe, effective and of good quality as they receive no information about patients once they have been discharged from their care. The lack of robust patient focussed outcome measures for ambulance care means there is no opportunity for identifying and sharing good practice, identifying problems and measuring the impact of service developments and innovations. Assessment of problem and analysis of its causes: Historically ambulance service performance has been measured using response time as a proxy measure for quality. Although the limitations of this measure are recognised there is a lack of consensus on which outcome measures are important and little opportunity to measure alternatives due to poor information on what happens to patients after their ambulance service contact. The PhOEBE NIHR research programme aims to develop a linked ambulance service and secondary care dataset and to assess quality of care in this patient group using outcome measures identified from the literature and in consultation with different stakeholder groups. This means that for the first time the ambulance service will be able to assess the quality of care they provide to patients, rather than just how quickly the ambulance arrived. Intervention: Potential outcome measures identified from 2 systematic reviews were categorised into 1 of 3 headings (Service/operational, patient management and patient outcomes) and participants were pre-allocated to a discussion group. All discussion groups contained participants representing a range of stakeholder view points. Participants took part in small group themed discussions relating to a number of pre-specified outcome measures. They were also able to add to the list of measures. Directly following the discussion participants voted on the importance of the outcome measures in relation to ambulance service care quality. This was done using Turning Point software. Participants rated each outcome measure as either ‘Essential’, ‘Desirable’ or ‘Irrelevant’ using individual key pads. The voting was done independently and anonymously. Real time results were displayed following each vote. Study design: We used an interactive voting system coupled with a modified nominal group technique for the prioritisation of potential ambulance service outcome measures. Strategy for change: Following on from this study the top ranking outcome measures will be further refined as part of a Delphi study, before using the outcome measures to assess ambulance service quality of care in our linked data sample. The methods for linking the ambulance service data to other health care information and the identified outcome measures will enable all UK ambulance services to assess the quality of care they provide to patients and the impact of any service changes on care quality and patient outcomes. Measurement of improvement: The results from the outcome prioritisation voting exercise were ranked based on the highest proportion of ‘Essential’ rated measures. Where over 50% of participants rated a measure as ‘Essential’ these were taken forward and considered in further consensus studies. Effects of changes: From undertaking the consensus event we have prioritised potential ambulance service outcome measures. Lessons learnt: We have established that it is possible to incorporate voting technology into consensus methodologies and provide real time results to participants. Message for others: This research prioritised ambulance service outcome measures. Out of the 40 number of measures considered, the top 5 measures were Accuracy of dispatch decisions; Completeness and accuracy of patient records; Accuracy of call taker identification of different conditions; pain measurement and symptom relief and Patient experience

Modelling Immunological Memory

Accurate immunological models offer the possibility of performing highthroughput experiments in silico that can predict, or at least suggest, in vivo phenomena. In this chapter, we compare various models of immunological memory. We first validate an experimental immunological simulator, developed by the authors, by simulating several theories of immunological memory with known results. We then use the same system to evaluate the predicted effects of a theory of immunological memory. The resulting model has not been explored before in artificial immune systems research, and we compare the simulated in silico output with in vivo measurements. Although the theory appears valid, we suggest that there are a common set of reasons why immunological memory models are a useful support tool; not conclusive in themselves

Developing new ways of measuring the impact of ambulance service care

Background Pre-hospital care in England is provided by ambulance services who deliver a diverse range of services to over 9 million patients a year but there is limited evidence about the effectiveness of this care. Historically ambulance performance has been measured by response times rather than clinical need or effectiveness. Progress on developing more appropriate performance measures is constrained by a lack of information about what happens to patients and their outcome after the pre-hospital component of care. If ambulance service information about patients could be linked to process and outcome data further along the care pathway then relevant measurement tools could be developed that allow a better assessment of the impact of pre-hospital care. The Pre-hospital Outcomes for Evidence Based Evaluation (PhOEBE) project is a 5 year programme of research funded by the UK National Institute of Health Research. Aims & objectives The aim of the programme is to develop new ways of measuring the impact of care provided by the ambulance service to support quality improvement through monitoring, audit and service evaluation. The objectives are to: 1) Review and synthesise the research literature on pre-hospital care outcome measures and identify measures relevant to the NHS and patients for further development; 2) Create a dataset linking routinely collected pre-hospital data, hospital data and mortality data to provide outcome information; 3) Develop new ways of measuring process and outcome indicators including building risk adjustment models that predict the outcomes using the linked data; 4) Explore the practical use of the linked dataset and the risk adjustment models to measure the effectiveness and quality of ambulance service care. Research plans The programme has 4 linked stages; 1. Synthesis of evidence on outcome measures and identification of measures for further development - review and assessment of the evidence base on outcome measurement for pre-hospital care and a consensus studies to identify measures relevant to patients and NHS staff. 2: Linking pre-hospital data with other patient data sources – creating a single dataset that links ambulance service electronic care records with routinely collected Hospital Episode Statistics (HES) and national mortality data. 3. Development of risk adjustment models for outcomes in patients attended by the ambulance service – using the linked data to develop risk adjustment tools that will allow patient differences to be taken into account and differences between expected and actual outcomes to be detected. Particular emphasis will be made to include the broad EMS population and not specific conditions as has been the case in the past. 4. Testing the risk adjustment models to assess if they can be used to measure effectiveness and quality – exploring the practical application of the measures by using them to assess if different ways of providing ambulance service care result in different consequences for patients. Outputs, outcomes and impact The programme will: • Provide a summary of relevant evidence on pre-hospital care outcome measurement • Develop a method for linking healthcare information into a format that can be used to support quality improvement, is acceptable to patients and complies with information legislation • Develop population based models for measuring the impact of pre-hospital care that can be used to monitor quality and safety, evaluate new service innovations and support quality improvement • Provide added value by using routine information and NHS infrastructure to operationalise the process and outcome models so that they will be of use across the NHS Progress to date The programme commenced in June 2011 and ends in May 2016. Two systematic reviews of measures used to measure the impact of ambulance service care (one policy literature and one research literature based) have been completed as has a qualitative study of recent service users to identify aspects of service they value. Potential measures identified by these studies were presented at a consensus conference and then further refined in a Delphi study to prioritise and identify measures for further development. Linked data is currently being created and the next stage will be the development of risk adjusted predictive models for the final identified measures

Prehospital outcomes for ambulance service care: systematic review

Background: Ambulance service performance measurement has previously focused on response times and survival. We conducted a systematic review of the international literature on quality measures and outcomes relating to pre-hospital ambulance service care, aiming to identify a broad range of outcome measures to provide a more meaningful assessment of ambulance service care. Methods: We searched a number of electronic databases including CINAHL, the Cochrane Library, EMBASE, Medline, and Web of Science. For inclusion, studies had to report either research or evaluation conducted in a pre-hospital setting, published in the English language from 1982 to 2011, and reporting either outcome measures or specific outcome instruments. Results: Overall, 181 full-text articles were included: 83 (46%) studies from North America, 50 (28%) from Europe and 21 (12%) from the UK. A total of 176 articles were obtained after examining 257 full-text articles in detail from 5,088 abstracts screened. A further five papers were subsequently identified from references of the articles examined and studies known to the authors. There were 140 articles (77%) which contained at least one survival-related measure, 47 (34%) which included information about length of stay and 87 (48%) which identified at least one place of discharge as an outcome. Limitations: We encountered the problem of incomplete information, for instance studies not specifying which pain scales when these had been used or using survival without a specific time period. Conclusion and recommendations: In addition to measures relating to survival, length of stay and place of discharge, we identified 247 additional outcome measures. Few studies included patient reported or cost outcomes. By identifying a wide range of outcome measures this review will inform further research looking at the feasibility of using a wider range of outcome measures and developing new outcome measures in prehospital research and quality improvement

Crohn's Disease in the Elderly: Prolonged Delay In Diagnosis

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/111187/1/j.1532-5415.1985.tb05462.x.pd