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Highlights • After implementing optimized model, we observed 34% reduction in supply chain costs. • Costs increased for Provincial store but decreased for Zones and health facilities. • Streamlined distribution practices supported cost reductions for transportation. • After implementing optimized model, costs increased in control Zones and facilities., Objective In 2017, an optimized immunization supply chain (iSC) model was implemented in Equateur Province, Democratic Republic of the Congo. The optimized model aimed to address iSC challenges and featured direct deliveries to service delivery points (SDPs), longer replenishment intervals and increased cold chain capacity. This assessment examines iSC costs before and 5 months after implementing the optimized model. Materials & Methods We used a nonexperimental pre-post study design to compare iSC costs before and after implementation. We applied an activity-based costing approach with a comparison arm to assess procurement, management, storage and transportation costs for three iSC tiers: Province (n = 1); Zone (n = 4) and SDP (n = 15). We included data from 3 treatment Zones and 11 treatment SDPs; 1 control Zone and 4 control SDPs. We used sample and population data to estimate iSC costs for the entirety of Equateur Province. Results In the period immediately before implementing the optimized model, estimated annual iSC costs were $974,237. Following implementation, estimated annual iSC costs were $642,627—a 34% ($331,610) reduction. This change in costs was influenced by a 43% ($180,313) reduction in SDP costs, a 67% ($198,092) reduction in Zonal costs and an 18% ($46,795) increase in Provincial costs. After implementing the optimized model, average iSC costs for treatment Zones was $6,895 (SD: $6,072); for the control Zone was $21,738; for treatment SDPs was $989 (SD: $969); and for control SDPs was $1,356 (SD: $1,062). Conclusions We observed an absolute reduction in iSC costs in treatment Zones while control Zone post-implementation iSC costs remained the same or increased. The greatest cost reductions were for storage and transport at Zones and SDPs. Although cost implications of this model must continue to be evaluated over time, these findings are promising and will inform decisions around project expansion.

Survival rates after cardiac arrest (CA) are increasing, with more patients and their families living with the psychological consequences of surviving a sudden CA. The currently available neuropsychological assessment tools and therapies were not designed for CA, and may be inadequate. The Essex Cardiothoracic Centre set up the United Kingdom's first dedicated multidisciplinary "Care After REsuscitation" (CARE) service, offering CA survivors and their caregivers systematic psychological, cognitive, and specialized medical support for the first 6 months after CA. Twenty-one patients were recruited into the CARE pilot service evaluation. Patients' health at hospital discharge was poor; however, by 6 months all components (except general health) had improved significantly, and were close to that experienced by "healthy" individuals. Five (26%) required referral to a psychiatrist, with all 5 (26%) subsequently being diagnosed with moderate-to-severe depression, and 3 (16%) with comorbid post-traumatic stress disorder. Our study demonstrates a large unmet clinical need in general and neuropsychological assessment, and our results suggest that offering appropriate and prompt specialist diagnosis and therapies leads to an improvement in health at 6 months.

Aim: \ud To determine the safety and feasibility of an early (12 h) waking and extubation protocol for out-of-hospital cardiac arrest (OHCA) patients receiving targeted temperature management (TTM).\ud \ud Methods: \ud This was a single-centre, prospective, non-randomised, observational, safety and feasibility pilot study which included successfully resuscitated OHCA patients, of presumed cardiac cause. Inclusion criteria were: OHCA patients aged over 18 years with a return of spontaneous circulation, who were going to receive TTM33 (TTM at 33 °C for 24 h and prevention of hyperthermia for 72 h) as part of their post cardiac arrest care. Clinical stability was measured against physiological and neurological parameters as well as clinical assessment.\ud \ud Results:\ud 50 consecutive patients were included (median age 65.5 years, 82% male) in the study. Four (8%) patients died within the first twelve hours and were excluded from the final cohort (n = 46). Twenty-three patients (46%) were considered clinically stable and suitable for early waking based on the intention to treat analysis; 12 patients were extubated early based on a variety of clinical factors (21.4 ± 8.6 h) whilst continuing to receive TTM33 with a mean core temperature of 34.2 °C when extubated. Of these, five patients were discharged from the intensive care unit (ICU)

Investments in a national logistics management unit and electronic logistics management information system resulted in better data use and improvements in some, but not all, management practices. After 1 year, key improvements included reduced stock-out rates, stock-out duration, and expiry rates. Although the upgraded systems were not inexpensive, they contributed to greater system efficiency and generated modest savings that defrayed much of the investment and maintenance costs., Background: To address challenges in public health supply chain performance, Tanzania invested in a national logistics management unit (LMU) and a national electronic logistics management information system (eLMIS). This evaluation examined the impact of those 2 key management upgrades approximately 1 year after they were introduced. Methods: We used a nonexperimental pre-post study design to compare the previous system with the upgraded management system. We collected baseline data from August to November 2013. We conducted round 1 of post-implementation data collection during April and May 2015, about 1 year after implementation of the upgrades. We evaluated key indicators of data use and reporting; supply chain management practices such as storage and supervision; supply chain performance including stock-out and expiry rates; and supply chain cost and savings. We analyzed the data using a range of techniques including statistical testing of baseline and round-1 results, and cost, cost-effectiveness, and return on investment analysis. Results: The upgrades were associated with improvements in data use, accessibility, visibility, and transparency; planning, control, and monitoring; support for quantification; stock-out rates; stock-out duration; commodity expiry; and forecast error. The upgraded system was more costly, but it was also more efficient, particularly when adjusting for the performance improvements. The upgrades also generated substantial savings that defrayed some, but not all, of the investment costs. Conclusion: Upgrades to Tanzania's supply chain management systems created multiple and complex pathways to impact. One year after implementation, the LMU and eLMIS brought about performance improvements through better data use and through improvements in some, but not all, management practices. Furthermore, the upgrades—while not inexpensive—contributed to greater system efficiency and modest savings.

Brain injury is the most common cause of mortality after return of spontaneous circulation following out of hospital cardiac arrest. European guidelines suggest a multimodal approach to neurological prognostication because of the difficulties associated with sedation, paralysing agents and mild

Introduction:\ud Trials demonstrate significant clinical benefit in patients receiving therapeutic hypothermia (TH) after cardiac arrest. However, incidence of mortality and morbidity remains high in this patient group. Rapid targeted brain hypothermia induction, together with prompt correction of the underlying cause may improve outcomes in these patients. This study investigates the efficacy of Rhinochill®, an intranasal cooling device over Blanketrol®, a surface cooling device in inducing TH in cardiac arrest patients within the cardiac catheter laboratory.\ud \ud Methods:\ud 70 patients were randomized to TH induction with either Rhinochill® or Blanketrol®. Primary outcome measures were time to reach tympanic ≤34 °C from randomisation as a surrogate for brain temperature and oesophageal ≤34 °C from randomisation as a measurement of core body temperature. Secondary outcomes included first hour temperature drop, length of stay in intensive care unit, hospital stay, neurological recovery and all-cause mortality at hospital discharge.\ud \ud Results:\ud There was no difference in time to reach ≤34 °C between Rhinochill® and Blanketrol® (Tympanic ≤34 °C, 75 vs. 107 mins; p = 0.101; Oesophageal ≤34 °C, 85 vs. 115 mins; p = 0.151). Tympanic temperature dropped significantly with Rhinochill® in the first hour (1.75 vs. 0.94 °C; p < 0.001). No difference was detected in any other secondary outcome measures. Catheter laboratory-based TH induction resulted in a survival to hospital discharge of 67.1%.\ud \ud Conclusion:\ud In this study, Rhinochill® was not found to be more efficient than Blanketrol® for TH induction, although there was a non-significant trend in favour of Rhinochill® that potentially warrants further investigation with a larger trial.

Mild therapeutic hypothermia (MTH 33°C) post out-of-hospital cardiac arrest (OHCA) is widely accepted as standard of care. However, uncertainty remains around the dose and therapy duration. OHCA patients are usually kept sedated±paralyzed and ventilated for the first 24-36 hours, which allows for targeted temperature management, but makes neurological prognostication challenging. The aim of this study is to investigate the feasibility and safety of assessing the unconscious OHCA patient after 12 hours for early waking/extubation while continuing to provide MTH for 24 hours, and fever prevention for 72 hours by using an intravenous temperature management (IVTM) system and established conscious MTH anti-shiver regimens. This is a single-center, prospective, non-randomized observational study that will compare the results of early awakening (at 12 hours) with historical controls. A total of 50 consecutive unconscious survivors of OHCA, treated with MTH, who meet the Therapeutic Hypothermia and eArly Waking (THAW) inclusion criteria will be enrolled. The patient will receive MTH by using IVTM. After 12 hours of MTH, patients will be assessed by using strict clinical criteria to determine suitability for early waking and extubation. Once awake and extubated, MTH will continue for 24 hours with skin counter-warming and anti-shiver regimen followed fever prevention up to 72 hours. All patients will have serial electroencephalogram (EEG), somatic sensory potential, and neuro-biomarkers performed on admission to intensive care unit, 6 and 12 hours, then every 24 hours until 72 hours. The study has been approved by the National Research Ethics Service, Health Research Authority.

European Resuscitation Council guidelines recommend screening for cognitive and emotional problems for all survivors of out-of-hospital cardiac arrest (OHCA), and prompt referral to a psychiatrist, psychologist or neuropsychologist when appropriate. In our specialist cardiac centre we have created the first care after resuscitation (CARE) clinic to offer cardiac arrest survivors and their carers psychological, cognitive and medical support up to 1 year after discharge from hospital. In our specialist centre, we see in excess of 70 OHCA survivors a year. …

We study the problem of a two-firm supply chain in which firms simultaneously choose a capacity before demand is realized. We focus on the role that private information about demand has on firms' ability to align their capacity decisions. When forecasts are private information, there are at most two equilibria: a complete coordination failure or a monotone equilibrium. The former equilibrium always exists, whereas the latter exists only when the marginal cost of capacity is sufficiently low. We also show that both truthful information sharing and preplay communication have an equilibrium with higher profits. We then test the model's predictions experimentally. Contrary to our theoretical predictions, we show that private demand forecasts do not have a consistently negative effect on firm profits, though capacities are more misaligned. We show that preplay communication may be more effective at increasing profits than truthful information sharing. Finally, we document that “honesty is the best policy” when communicating private information.

In most organizations, supply chain planning is a cross-functional effort. However, functional areas such as sales, marketing, finance, and operations traditionally specialize in portions of the planning activities, which results in conflicts over expectations, preferences, and priorities. We report findings from a detailed case analysis of a supply chain planning process that seemingly weathers these cross-functional conflicts. In contrast to traditional research on this area, which focuses on incentives, responsibilities, and structures, we adopt a process perspective and find that integration was achieved despite formal functional incentives that did not support it. By drawing a distinction between the incentive landscape and the planning process, we identify process as a mediator that can affect organizational outcomes. Thus, organizations may be capable of integration while functions retain different incentives and orientations to maintain focus on their stakeholders’ needs. Through iterative coding, we identify the attributes of the planning process that can drive planning performance—information, procedural, and alignment quality—but also find evidence that achieving alignment in the execution of plans can be more important than informational and procedural quality. In addition to process attributes, we also identify social elements that influenced the performance of the planning process and place the information processing attributes within a broader social and organizational context.

To date, little research has been done on managing the organizational and political dimensions of generating and improving forecasts in corporate settings. We examine the implementation of a supply chain planning process at a consumer electronics company, concentrating on the forecasting approach around which the process revolves. Our analysis focuses on the forecasting process and how it mediates and accommodates the functional biases that can impair the forecast accuracy. We categorize the sources of functional bias into intentional, driven by misalignment of incentives and the disposition of power within the organization, and unintentional, resulting from informational and procedural blind spots. We show that the forecasting process, together with the supporting mechanisms of information exchange and elicitation of assumptions, is capable of managing the potential political conflict and the informational and procedural shortcomings. We also show that the creation of an independent group responsible for managing the forecasting process, an approach that we distinguish from generating forecasts directly, can stabilize the political dimension sufficiently to enable process improvement to be steered. Finally, we find that while a coordination system—the relevant processes, roles and responsibilities, and structure—can be designed to address existing individual and functional biases in the organization, the new coordination system will in turn generate new individual and functional biases. The introduced framework of functional biases (whether those biases are intentional or not), the analysis of the political dimension of the forecasting process, and the idea of a coordination system are new constructs to better understand the interface between operations management and other functions.

Patients presenting with ST elevation myocardial infarction (STEMI) are routinely treated with percutaneous coronary intervention to restore blood flow in the occluded artery to reduce infarct size (IS). However, there is evidence to suggest that the restoration of blood flow can cause further damage to the myocardium through reperfusion injury (RI). Recent research in this area has focused on minimizing damage to the myocardium caused by RI. Therapeutic hypothermia (TH) has been shown to be beneficial in animal models of coronary artery occlusion in reducing IS caused by RI if instituted early in an ischemic myocardium. Data in humans are less convincing to date, although exploratory analyses suggest that there is significant clinical benefit in reducing IS if TH can be administered at the earliest recognition of ischemia in anterior myocardial infarction. The Essex Cardiothoracic Centre is the first UK center to have participated in administering TH in conscious patients presenting with STEMI as part of the COOL-AMI case series study. In this article, we outline our experience of efficiently integrating conscious TH into our primary percutaneous intervention program to achieve 18 minutes of cooling duration before reperfusion, with no significant increase in door-to-balloon times, in the setting of the clinical trial.

Decentralized supply chains are traditionally order focused: stage managers focus on meeting replenishment orders of downstream stages; market demand information is relayed up through these orders, and therefore is subject to costly delay and distortion. This paper shows that sharing real-time sales data across all stages and a change in focus to meeting customer demand can mitigate performance impairment caused by the order focus. We show that a change of managerial focus in a decentralized chain can be made by measuring stages’ performance based on their respective echelon stocks, which only depends on how well they respond to the market demand. A demand-focused measurement scheme can be made incentive compatible with the knowledge of the demand distribution; a heuristic scheme independent of the demand distribution can be used to achieve near incentive compatibility.

Background: Malaria rapid diagnostic tests (RDTs) are particularly useful in low-resource settings where follow-through on traditional laboratory diagnosis is challenging or lacking. The availability of these tests depends on supply chain processes within the distribution system. In Mozambique, stock-outs of malaria RDTs are fairly common at health facilities. A longitudinal cross-sectional study was conducted to evaluate drivers of stock shortages in the Cabo Delgado province. Methods: Data were collected from purposively sampled health facilities, using monthly cross-sectional surveys between October 2011 and May 2012. Estimates of lost consumption (consumption not met due to stock-outs) served as the primary quantitative indicator of stock shortages. This is a better measure of the magnitude of stock-outs than binary indicators that only measure frequency of stock-outs at a given facility. Using a case study based methodology, distribution system characteristics were qualitatively analysed to examine causes of stock-outs at the provincial, district and health centre levels. Results: 15 health facilities were surveyed over 120 time points. Stock-out patterns varied by data source; average monthly proportions of 59%, 17% and 17% of health centres reported a stock-out on stock cards, laboratory and pharmacy forms, respectively. Estimates of lost consumption percentage were significantly high; ranging from 0% to 149%; with a weighted average of 78%. Each ten-unit increase in monthly-observed consumption was associated with a nine-unit increase in lost consumption percentage indicating that higher rates of stock-outs occurred at higher levels of observed consumption. Causes of stock-outs included inaccurate tracking of lost consumption, insufficient sophistication in inventory management and replenishment, and poor process compliance by facility workers, all arguably stemming from inadequate attention to the design and implementation of the distribution system. Conclusions: Substantially high levels of RDT stock-outs were found in Cabo Delgado. Study findings point to a supply chain with a commendable degree of sophistication. However, insufficient attention paid to system design and implementation resulted in deteriorating performance in areas of increased need. In such settings fast moving commodities like malaria RDTs can call attention to supply chain vulnerabilities, the findings from which can be used to address other slower moving health commodities.

Managing Cardiac Arrest after Cardiac Surgery: The Impact of a Five Year Evolving Re-Sternotomy Policy and a Review of the Literature Although advances in knowledge and improvements in managing cardiac arrest resulting from research, training and implementation of guidelines has led to vast improvements in survival, the outcomes are still generally poor. Cardiac arrest in patients who have undergone cardiac surgery present different management challenges and is associated with a better prospect of successful outcome. In acknowledgement of this fact, the European Resuscitation Council published a specific section on resuscitation of patients with cardiac arrest after cardiac surgery in 2005.

Background Primary PCI is the gold standard treatment for acute STEMI, but reperfusion injury limits its beneficial effect on infarct size (IS). In experimental studies, therapeutic hypothermia (HT) consistently reduces IS caused by reperfusion injury, but translation into clinical practice remains a challenge. The purpose of our study (part of COOL AMI EU study) was to assess the feasibility of integrating pre-reperfusion HT using an intravascular temperature management system (Thermogard XP, ZOLL, USA) into routine clinical practice without a significant delay in door-to-balloon (DTB) time. Methods Patients with STEMI presenting within 6 h of symptoms onset and planned for PPCI were prospectively enrolled. TH was implemented by intravenous infusion (IV) of cold saline and a heat-exchange balloon catheter inserted via the right femoral vein. Oral buspirone and IV pethidine were used to control shivering. HT was continued for a total time of 3 h, followed by passive rewarming. Results 18 patients were successfully recruited. The average age was 60.3 years and 94.4% were male. The DTB time was 40.6 min. There was an increase of 3.6 min compared with the mean DTB time of 37 min for patients who underwent PPCI and did not received HT. Mean temperature at reperfusion was 34.4 ° C. There were no adverse events related to the use of the heat-exchange catheter or the implementation of hypothermia. Conclusion Hypothermia is feasible and safe in STEMI patients without significant delay in door-to-balloon time.

We study the coordination problem of a two-firm supply chain in which firms simultaneously choose a capacity before demand is realized. We focus on the role that (a lack of) common knowledge of demand forecasts has on firms' ability to align their capacity decisions. When forecasts are not common knowledge, there are at most two equilibria: A complete coordination failure or a monotone equilibrium in which firms earn strictly positive profits. The former equilibrium always exists, while the latter exists only when the marginal cost of capacity is sufficiently low. In the monotone equilibrium, capacities are misaligned with probability 1 and profits are lower than in the efficient equilibrium of the common knowledge game. We also show that firms have an incentive to share their information. In a series of experiments, we test the model's predictions. We find that: (1) most subjects use monotone strategies and those that do not earn significantly less; (2) when forecasts are not common knowledge, alignment often suffers, though profits do not; (3) information sharing improves earnings through greater accuracy and alignment; and (4) subjects learn to align their decisions, and earnings increase, over time.

In this paper we propose a perceptions framework for categorizing a range of inventory decision making that can be employed in a single-stage supply chain. We take the existence of a wide range of inventory decision making processes, as given and strive not to model the reasons that the range persists but seek a way to categorize them via their effects on inventory levels, orders placed given the demand faced by the inventory system. Using a perspective that we consider natural and thus appealing, the categorization involves the use of conceptual perceptions of demand to underpin the link across three features of the inventory system: inventory levels, orders placed and actual demand faced. The perceptions framework is based on forecasting with Auto-Regressive Integrated Moving Average (ARIMA) time series models. The context in which we develop this perceptions framework is of a single stage stochastic inventory system with periodic review, constant leadtimes, infinite supply, full backlogging, linear holding and penalty costs and no ordering costs. Forecasting ARIMA time series requires tracking forecast errors (interpolating) and using these forecast errors and past demand realizations to predict future demand (extrapolating). So called optimal inventory policies are categorized here by perceptions of demand that align with reality. Naturally then, deviations from optimal inventory policies are characterized by allowing the perception about demand implied by the interpolations or extrapolations to be primarily different from the actual demand process. Extrapolations and interpolations being separate activities, can in addition, imply differing perceptions from each other and this can further categorize inventory decision making.

Introduction In the UK, an estimated 30,000 out of hospital cardiac arrests (CA) are treated by emergency medical services annually. Better access to early chain of survival is expected to result in improved survival rates. Therefore, more patients are expected to live with the consequence of the CA, which can range from impairment of cognitive function, deterioration in emotional well-being and perceived quality of life (QoL). Follow-up of patients at the Essex Cardiothoracic Centre, in a current research trial involving CA survivors, emphasised that standard psychological support arrangements for these patients and their caregivers are alarmingly inadequate. Last year in the Netherlands, a randomised trial demonstrated that introduction of early psychological support service significantly improved QoL for survivors of CA compared with control group, paving the way for this to be incorporated in routine clinical practice. This study also showed that a higher percentage of patients (50%) receiving the intervention returned to work 3 months after CA compared to 21% in the control group. Methods and results In the setting of the CARE after resuscitation trial, we are the first NHS trust investigating the effects of a comprehensive psychological support service in patients following CA. In group 1, 20 patients and their caregivers have been recruited at least 3 months after the CA, to assess the effectiveness of current ‘standard care’. About 50% of these patients still experienced moderate to severe depression, 20% suffered from post-traumatic stress disorder and they were referred to a clinical psychiatrist for further management. In group 2, a further 20 patients, after surviving a CA with good neurological recovery and their caregivers are reviewed on the ward prior to discharge by a senior ICU nurse and a cardiologist. They are given a leaflet detailing life after cardiac arrest and the support network in place, and given a novel telephone help line (managed by ICU nurses that they can call during working hours). Once discharged patients are contacted by the ICU nurse within 48 h to ask about their well-being. Patients and caregivers are then invited back to a dedicated cardiac arrest outpatient clinic after 6–8 weeks, where they are seen by a multi-disciplinary team including cardiologist, ICU nurse and psychiatrist. Patients and their caregivers will then be reviewed in 6 months to re-evaluate their QoL and their ability to return to work. Conclusion We hope that the observations from the Netherlands can be replicated here in the “intervention group” and these data will be presented at the BCS conference in June 2015. If successful, we will disseminate our experience with the rest of the UK so that, all survivors of CA and their caregivers can benefit from this service.

In this article, we study behavior in a series of two-player supply chain game experiments. Each player simultaneously chooses a capacity before demand is realized, and sales are given by the minimum of realized demand and chosen capacities. We focus on the differences in behavior under fixed pairs and random rematching. Intuition suggests that long-run relations should lead to more profitable outcomes. However, our results go against this intuition. While subjects' capacity choices are better aligned (i.e., closer together) under fixed pairs, average profits are more variable. Moreover, learning is slower under fixed pairs�so much so that over the last five periods, average profits are actually higher under random rematching. The underlying cause for this finding appears to be a �first-impressions� bias, present only under fixed matching, in which the greater the misalignment in initial choices, the lower are average profits.