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ObjectiveHospital-acquired pressure injuries are localised skin injuries that cause significant mortality and are costly. Nursing best practices prevent pressure injuries, including time-consuming, complex tasks that lack payment incentives. The Braden Scale is an evidence-based stratification tool nurses use daily to assess pressure-injury risk. Our objective was to analyse the cost-utility of performing repeated risk-assessment for pressure-injury prevention in all patients or high-risk groups.DesignCost-utility analysis using Markov modelling from US societal and healthcare sector perspectives within a 1-year time horizon.SettingPatient-level longitudinal data on 34 787 encounters from an academic hospital electronic health record (EHR) between 2011 and 2014, including daily Braden scores. Supervised machine learning simulated age-adjusted transition probabilities between risk levels and pressure injuries.ParticipantsHospitalised adults with Braden scores classified into five risk levels: very high risk (6–9), high risk (10–11), moderate risk (12–14), at-risk (15–18), minimal risk (19–23).InterventionsStandard care, repeated risk assessment in all risk levels or only repeated risk assessment in high-risk strata based on machine-learning simulations.Main outcome measuresCosts (2016 $US) of pressure-injury treatment and prevention, and quality-adjusted life years (QALYs) related to pressure injuries were weighted by transition probabilities to calculate the incremental cost-effectiveness ratio (ICER) at $100 000/QALY willingness-to-pay. Univariate and probabilistic sensitivity analyses tested model uncertainty.ResultsSimulating prevention for all patients yielded greater QALYs at higher cost from societal and healthcare sector perspectives, equating to ICERs of $2000/QALY and $2142/QALY, respectively. Risk-stratified follow-up in patients with Braden scores 99% of probabilistic simulations.ConclusionOur analysis using EHR data maintains that pressure-injury prevention for all inpatients is cost-effective. Hospitals should invest in nursing compliance with international prevention guidelines.

Objective In December 2016, 66 health leaders from 14 countries convened at the Salzburg Global Seminar (SGS) to engage in cross-cultural and collaborative discussions centered on 'Rethinking Care Toward the End of Life'. Conversations focused on global perspectives on death and dying, challenges experienced by researchers, physicians, patients and family caregivers. This paper summarizes key findings and recommendations from SGS. Design Featured sessions focused on critical issues of end of life care led by key stakeholders, physicians, researchers, and other global leaders in palliative care. Sessions spanned across several critical themes including: patient/family/caregiver engagement, integrating health and community-based social care, eliciting and honoring patient preferences, building an evidence base for palliative care, learning from system failures, and delivering end of life care in low-resource countries. Sessions were followed by intensive collaborative discussions which helped formulate key recommendations for rethinking and ultimately advancing end of life care. Results Prominent lessons learned from SGS include learning from low-resource countries, development of evidence-based quality measures, implementing changes in training and education, and respecting the personal agency of patients and their families. Conclusion There is a global need to rethink, and ultimately revolutionize end of life care in all countries. This paper outlines key aspects of end of life care that warrant explicit improvement through specific action from key stakeholders.

A PSA level-3 study has been carried out for postulated accidental release from an Indian PHWR. Postulated release due to triple failures (LBLOCA with simultaneous failure of ECCS and containment isolation failure) in typical 220 MWe Indian PHWR is simulated in this study to know the impact of accident. The principal phenomenon for atmospheric transport of effluent is considered using a Gaussian plume model, MUSEMET which takes hourly variation of meteorological condition into account. Site-specific meteorological and demographic data has been considered for this study. Appropriate meteorological sampling has been done to represent 5-year meteorological data and severity of accident. COSYMA Code is used for calculation of projected doses for seven days to estimate the area and persons affected after implementation of urgent protective actions on the basis of IAEA GSR Part-7. As an element of emergency response planning, affected sector and area are determined under variety of meteorological conditions. The protection offered by iodine prophylaxis and sheltering has been emphasized in this study. Sheltering can be effective by keeping the public out of the plume exposure pathway during the time when the radioactive concentration of plume is high and iodine prophylaxis will avert thyroid dose significantly if taken at appropriate time. The effect of accident in public domain can be minimized effectively using proper countermeasures strategies. Further, risk to public and health effects has been found limited in this study.

In last few years, cancer became one of the leading cause of death in humans. There are several factors associated with the cancer initiation and progression including heavy metals. Several heavy metals including arsenic, cadmium, uranium, lead, mercury etc. and heavy metal-containing compounds are toxic to the humans and have been reported to induce mutations in human genome which further leads to the carcinogenesis. This chapter provides the detail understanding of molecular mechanisms and pathway analysis to heavy metal toxicity in human carcinogenesis.

Purpose: To explore the methods through which physicians deliver compassionate care during end-of-life (EOL). Compassionate care provides benefits to patients and providers and is particularly important for patients with serious illnesses, yet its practice remains limited. We aim to qualitatively characterize methods utilized by physicians that facilitate the delivery of compassionate care at EOL. Methods: We conducted 13 semi-structured interviews with physicians from palliative care and medical oncology subspecialities at a rural academic medical centre in New Hampshire. Interviews were transcribed and analysed using a qualitative research design. Results: Participants described methods of compassionate care ranging from symptom control to less tangible, non-verbal methods. Primary barriers to the delivery of compassionate care were described as within the broader healthcare system and within the inherent emotional difficulty of EOL care. Physicians from both subspecialities emphasized the importance of successful inter-provider relationships. Conclusions: Methods for delivering compassionate care at EOL are wide ranging, but barriers on a systemic and individual level should be addressed to make its practice more widespread. This can be accomplished, in part, by the standardization of EOL conversations, training physicians how to have meaningful EOL conversations, and integration of such conversations into electronic medical records.

In 2008, the Centers for Medicare and Medicaid Services (CMS) established nonpayment policies resulting from costliness of hospital-acquired pressure ulcers (HAPUs) to hospitals. This prompted hospitals to adopt quality improvement (QI) interventions that increase use of evidence-based practices (EBPs) for HAPU prevention.To evaluate the longitudinal impact of CMS policy and QI adoption on HAPU rates.We characterized longitudinal adoption of 25 QI interventions that support EBPs through hospital leadership, staff, information technology, and performance and improvement. Quarterly counts of HAPU incidence and inpatient characteristics were collected from 55 University HealthSystem Consortium hospitals between 2007 and 2012. Mixed-effects regression models tested the longitudinal association of CMS policy, HAPU coding, and QI on HAPU rates. The models assumed level-2 random intercepts and random effects for CMS policy and EBP implementation to account for between-hospital variability in HAPU incidence.Controlling for all 25 QI interventions, specific updates to EBPs for HAPU prevention had a significant, though modest reduction on HAPU rates (-1.86 cases/quarter; P=0.002) and the effect of CMS nonpayment policy on HAPU prevention was much greater (-11.32 cases/quarter; P0.001).HAPU rates were significantly lower after changes in CMS reimbursement. Reductions are associated with hospital-wide implementation of EBPs for HAPU prevention. Given that administrative data were used, it remains unknown whether these improvements were due to changes in coding or improved quality of care.

The concentrations of total dissolved uranium (U), its isotopic composition ((234)U, (235)U, (238)U) and two long lived Ra isotopes ((226)Ra and (228)Ra) in alluvial aquifers of groundwater were determined to investigate the groundwater flow pattern in the south-western (SW) Punjab, India. Particular attention was given to the spatial variability of activity ratios (ARs) of (234)U/(238)U and (226)Ra/(228)Ra to predict the possible sources and supply process of U into the water from the solid phase. The measured groundwater (234)U/(238)U ARs were ∼1 or1 in the shallow zone (depth 30 m) with high U concentration and1 in the deeper zone (depth 30 m) with relatively low U concentration. The simultaneous elevated U concentration and (234)U/(238)U ARs in waters were possibly due to differences in imprints of rock-water interactions under hydrologic conditions. However, (234)U/(238)U ARs 1 clearly indicate the lack of recharge from surface water to groundwater leading to (234)U deficit in groundwater. This deficit might be also attributed to alpha recoil processes under strong dissolution. Overall, the decreasing pattern of (234)U/(238)U ARs observed from SE to SW or NW ward clearly indicates a groundwater flow paths from SE to SW/NW. Similarly, (226)Ra/(238)U ARs 1 for all water samples reflect that the precursor (238)U is fairly mobile relative to (226)Ra. This might be due to unusually high amount of (238)U in groundwaters and subsequently the different geochemistry of the two isotopes. On the other hand, (226)Ra/(228)Ra ARs in groundwaters varied widely and observed about 50-300 times higher than (238)U/(232)Th ARs in granitic rocks or soils. Such elevation in ARs might be attributed to different dissolution properties of their parents during water-rock interactions or lattice damage during decay or local enrichments of uranium in the aquifers.

Background/objective In nursing homes across the world, and particularly in Spain, there are concerns that psychotropic medications are being overused. For older Spanish nursing home residents who had dementia, we sought to evaluate the association between applying interventions designed to reduce inappropriate psychotropic medication use and subsequent psychotropic use. Design Retrospective, propensity score-matched, controlled, patient-level observational analysis. Setting A total of 45 nursing homes in Spain. Participants A total of 1653 nursing home residents, aged 70 to 99 years, who had dementia and were prescribed an antipsychotic, anxiolytic, or antidepressant medication, 606 of whom received an intervention; the remainder served as propensity score-matched controls. Intervention Team Rounds, Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert Doctors to Right Treatment (START) criteria, or a Patient Decision Aid. Measurements At 2 and 4 weeks following intervention: change from baseline drug class-specific milligram-equivalent daily dose (MEDD); at 2 weeks: patient falls and restraint use. Results Within each intervention/drug-class cohort, intervention patients and matched controls had similar baseline demographic characteristics, Charlson scores, lengths of admission, and drug class-specific MEDDs. Compared to controls, patients exposed to Team Rounds experienced a 23.3% (95% confidence interval [CI] = 13.9%-32.8%) reduction in antipsychotic and a 23.1% (95% CI = 18.3%-28.0%) reduction in anxiolytic MEDDs; those exposed to Patient Decision Aids had a 24.8% (95% CI = 15.6%-33.9%) reduction in antipsychotic and a 31.8% (95% CI = 25.5%-38.2%) reduction in anxiolytic MEDDs; and those exposed to STOPP/START application had a 27.7% (95% CI = 22.4%-33.0%) reduction in antipsychotic and a 39.5% (95% CI = 35.5%-43.5%) reduction in anxiolytic MEDDs. Intervention-associated antidepressant MEDD reductions were statistically significant but less dramatic. Interventions were associated with higher rates of medication discontinuation, but not higher rates of deaths, patient falls, or physical restraints. Conclusion We found strong evidence that the interventions we studied were associated with reduced psychotropic use without commensurate harms, suggesting that such interventions should be incorporated into Spanish nursing home care models. Public reporting of psychotropic medication use in Spanish care homes may encourage care homes to regularly monitor psychotropic medication use and implement such instruments. J Am Geriatr Soc, 2019.

Background People with psychosis struggle with decisions about their use of antipsychotics. They often want to reduce the dose or stop, while facing uncertainty regarding the effects these decisions will have on their treatment and recovery. They may also fear raising this issue with clinicians. The purpose of this study was to develop and test a shared decision making (SDM) tool to support patients and clinicians in making decisions about antipsychotics. Methods A diverse editorial research team developed an Encounter Decision Aid (EDA) for patients and clinicians to use as part of the psychiatric consultation. The EDA was tested using 24 semistructured interviews with participants representing six stakeholder groups: patients with first-episode psychosis, patients with long-term psychosis, family members, psychiatrists, mental health counselors, and administrators. We used inductive and deductive coding of interview transcripts to identify points to revise within three domains: general impression and purpose of the EDA; suggested changes to the content, wording, and appearance; and usability and potential contribution to the psychiatric consultation. Results An EDA was developed in an iterative process that yielded evidence-based answers to five frequently asked questions about antipsychotic medications. Patients with long-term psychosis and mental health counselors suggested more changes and revisions than patients with first-episode psychosis and psychiatrists. Family members suggested more revisions to the answers about potential risks of stopping or adjusting antipsychotics than other respondents. Conclusions The EDA was perceived as potentially useful and feasible in psychiatric routine care, especially if presented during the consultation. Electronic supplementary material The online version of this article (10.1186/s12888-018-1707-x) contains supplementary material, which is available to authorized users.

The vertical downward migration of 238U in soils collected from south-western Punjab was studied from the depth distributions using the diffusion–convection model. The time-dependent convective rates (ν) of 238U were found to be in the order of 10−7–10−4 cm year−1, whereas under the assumption of steady state (time-independent), values were in the order of 10−5–10−4 cm year−1. However, the diffusion rates (D) were in the order of 10−6–10−3 cm2 year−1 and under the steady state, values obtained to be relatively higher as 0.002–0.70 cm2 year−1. These values were within the range of reported literature values.

Objective In 2008, the U.S. Centers for Medicare and Medicaid Services enacted a nonpayment policy for stage III and IV hospital-acquired pressure ulcers (HAPUs), which incentivized hospitals to improve prevention efforts. In response, hospitals looked for ways to support implementation of evidence-based practices for HAPU prevention, such as adoption of quality improvement (QI) interventions. The objective of this study was to quantify adoption patterns of QI interventions for supporting evidence-based practices for HAPU prevention. Methods This study surveyed wound care specialists working at hospitals within the University HealthSystem Consortium. A questionnaire was used to retrospectively describe QI adoption patterns according to 25 HAPU-specific QI interventions into four domains: leadership, staff, information technology (IT), and performance and improvement. Respondents indicated QI interventions implemented between 2007 and 2012 to the nearest quarter and year. Descriptive statistics defined patterns of QI adoption. A t-test and statistical process control chart established statistically significant increase in adoption following nonpayment policy enactment in October 2008. Increase are described in terms of scope (number of QI domains employed) and scale (number of QI interventions within domains). Results Fifty-three of the 55 hospitals surveyed reported implementing QI interventions for HAPU prevention. Leadership interventions were most frequent, increasing in scope from 40% to 63% between 2008 and 2012; “annual programs to promote pressure ulcer prevention” showed the greatest increase in scale. Staff interventions increased in scope from 32% to 53%; “frequent consult driven huddles” showed the greatest increase in scale. IT interventions increased in scope from 31% to 55%. Performance and improvement interventions increased in scope from 18% to 40%, with “new skin care products . . .” increasing the most. Linking Evidence to Action Academic medical centers increased adoption of QI interventions following changes in nonpayment policy. These QI interventions supported adherence to implementation of pressure ulcer prevention protocols. Changes in payment policies for prevention are effective in QI efforts.

OBJECTIVES\ud To revise an existing three-talk model for learning how\ud to achieve shared decision making, and to consult\ud with relevant stakeholders to update and obtain wider\ud engagement.\ud \ud DESIGN\ud Multistage consultation process.\ud \ud SETTING\ud Key informant group, communities of interest, and\ud survey of clinical specialties.\ud \ud PARTICIPANTS\ud 19 key informants, 153 member responses from\ud multiple communities of interest, and 316 responses\ud to an online survey from medically qualified clinicians\ud from six specialties.\ud \ud RESULTS\ud After extended consultation over three iterations, we\ud revised the three-talk model by making changes to\ud one talk category, adding the need to elicit patient\ud goals, providing a clear set of tasks for each talk\ud category, and adding suggested scripts to illustrate\ud each step. A new three-talk model of shared decision\ud making is proposed, based on “team talk,” “option\ud talk,” and “decision talk,” to depict a process of\ud collaboration and deliberation. Team talk places\ud emphasis on the need to provide support to patients\ud when they are made aware of choices, and to elicit\ud their goals as a means of guiding decision making\ud processes. Option talk refers to the task of comparing\ud alternatives, using risk communication principles.\ud Decision talk refers to the task of arriving at decisions\ud that reflect the informed preferences of patients,\ud guided by the experience and expertise of health\ud professionals.\ud \ud CONCLUSIONS\ud The revised three-talk model of shared decision\ud making depicts conversational steps, initiated by\ud providing support when introducing options, followed\ud by strategies to compare and discuss trade-offs,\ud before deliberation based on informed preferences.

Health-care delivery is a complex and fragmented system with work-around culture. Improving health-care delivery requires innovating system interventions that redesign processes for consistent implementation of evidence-based practices (EBPs). Systems engineering is an approach that involves anticipating ineffective processes that jeopardize quality, and designing interventions to overcome such shortcomings. This approach is based on systems teaching about reflexivity, which when addressed can support consistent EBP and assesses how the newly designed system meets this consistency. Integrating a systems engineering approach to implementing EBP may effectively address complex issues such as hospital-acquired pressure ulcer prevention, which has an EBP protocol that is not consistently implemented without system redesign. Engineering approaches and methods including Plan-Do-Study-Act (PDSA), Situation-Background-Assessment-Recommendations (SBAR), stochastic modeling, House of Quality, and statistical process control charts with lean six sigma provide a structured approach to identifying points of successful implementation for EBPs that can subvert work-around culture. This perspective piece reviews successful approaches of systems engineering to solve the problem of clinical work-arounds and puts forward the case for its wider application to health-care delivery systems that could benefit from standardized EBPs.

Measurements of the vertical concentration profile of deposited 210Pb and its parent (226Ra) in cores of recent marine sediment of Mumbai Harbor Bay (MHB) were made to determine the various depth distribution parameters (sedimentation rate, age of sediment, total inventory, fluxes, residence times, scavenging rate, linear attenuation coefficient and relaxation mass depth). Overall, the profile distributions of 226Ra and 210Pb showed a decreasing trend with increasing the depth. The mean of sedimentation rate in the studied area was obtained to be about 0.76 cm year−1 which corresponds to average age of sediment of about 56 years. The average total deposited 210Pb for the studied sediment profile was 9.68 k Bq m−2 and correspondingly the average value of fluxes of total 210Pb and excess 210Pb (atmospheric flux) were 0.59 and 0.32 k Bq m−2 year−1, respectively. The residence time of 210Pb was in the range of 26–226 years throughout the sediment profile and showed generally an increasing trend from top to bottom. The mean relaxation mass depth (h0) derived from the depth profile of 210Pb at the studied area was about 190 kg m−2. The negative association between clay content of cores and the h0 of 210Pb indicates that as the clay content increases, the penetration depth of deposited 210Pb in sediment profile decreases.

Groundwaters (borewell and handpump) were sampled from two districts (Bathinda and Mansa) of Punjab state and analyzed for their major ionic concentrations and uranium isotope compositions in order to assess the possible origins of the waters and water–rock interactions that occurred in the deep aquifer system. The major ionic concentrations of waters were plotted on a Piper diagram and grouped into four dominant hydrochemical facies as (Na+K)-SO4+Cl type (69% – 73%), (Ca+Mg)-SO4+Cl type (6% – 21%), (Ca+Mg)–HCO3 type (4% – 6%) and (Na+K)-HCO3 type (2% – 19%). It was observed that mobility of uranium in groundwater was very much influenced by TDS (total dissolved solids). To investigate the various mechanisms for deriving the elevated uranium concentrations in groundwater, 234U/238U activity ratios (ARs) were calculated using the determined activity levels of 234U and 238U. The mean ARs was found to be near unity (i.e. secular equilibrium) in the study regions confirmed that uranium in groundwaters was mainly resulted from its host/parent rocks through weathering processes. The concentration of HCO3 − in ground water showed one order of magnitude higher than the total dissolved SiO2 indicates that carbonate weathering was the dominant process due to major water–rock interaction. The uranium speciation in groundwaters was investigated by an equilibrium model calculation using MEDUSA (make equilibrium diagrams using sophisticated algorithms) under the influence of redox conditions and complexant concentration. At the observed range of pH values, the predominant redox speciation of uranium was observed as hydroxo-carbonato complexes of (UO2)2(CO3)(OH)3 − and hydroxyl complexes of UO2(OH)3 − which might be caused for increasing the solubility of uranium. Due to very low concentration of phosphate in groundwater, its effects on U(VI)-aqueous speciation was negligible.

ObjectiveTo develop and pilot an encounter-based decision aid (eDA) for people with depression for use in primary care.DesignWe developed an eDA for depression through cognitive interviews and pilot tested it using a one-group pretest, post-test design in primary care. Feasibility, fidelity of eDA use and acceptability were assessed using recruitment rates and semistructured interviews with patients, medical assistants and clinicians. Treatment choice and shared decision-making (SDM) were also assessed.SettingInterviews with adult patients and the public were conducted in a mall and library in Grafton County, New Hampshire, while clinician interviews took place by phone or at the clinician’s office. Pilot testing occurred in a New Hampshire primary care practice.ParticipantsCognitive interviews were conducted with adults, ≥18 years, who could read English from the following stakeholder groups: history of depression, the public and clinicians. Patients with a Patient Health Questionnaire-9 score of ≥5 were recruited for piloting.ResultsThree stages of cognitive interviews were conducted (n=28). Changes to eDA included moving the combination therapy information and access to treatment information, adding colour, modifying pictograms and editing the talk-therapy description. Clinician concerns about patient health literacy were not reflected in patient interviews. Of 59 patients who reviewed study information, 56 were eligible and agreed to participate in pilot testing; however, only 29 could be reached for follow-up. The eDA was widely accepted, though clinicians did not always use it as intended. We found no impact of eDA use on SDM, though patients chose a wider range of treatment options.ConclusionsWe demonstrated the feasibility of the use of an eDA for depression in primary care that was widely accepted. Further research is needed to improve the fidelity with which the eDA is used and to assess its impact on SDM and related health outcomes.

Objective: Hospital-acquired pressure ulcers (HAPUs) have a mortality rate of 11.6%, are costly to treat, and result in Medicare reimbursement penalties. Medicare codes HAPUs according to Agency for Healthcare Research and Quality Patient-Safety Indicator 3 (PSI-03), but they are sometimes inappropriately coded. The objective is to use electronic health records to predict pressure ulcers and to identify coding issues leading to penalties. Materials and Methods: We evaluated all hospitalized patient electronic medical records at an academic medical center data repository between 2011 and 2014. These data contained patient encounter level demographic variables, diagnoses, prescription drugs, and provider orders. HAPUs were defined by PSI-03: stages III, IV, or unstageable pressure ulcers not present on admission as a secondary diagnosis, excluding cases of paralysis. Random forests reduced data dimensionality. Multilevel logistic regression of patient encounters evaluated associations between covariates and HAPU incidence. Results: The approach produced a sample population of 21 153 patients with 1549 PSI-03 cases. The greatest odds ratio (OR) of HAPU incidence was among patients diagnosed with spinal cord injury (ICD-9 907.2: OR = 14.3; P Discussion: This analysis identifies spinal cord injuries as high risk for HAPUs and as being often inappropriately coded without paralysis, leading to PSI-03 flags. The resulting statistical model can be tested to predict HAPUs during hospitalization. Conclusion: Inappropriate coding of conditions leads to poor hospital performance measures and Medicare reimbursement penalties.

Contains fulltext : 167238.pdf (Publisher’s version ) (Open Access) OBJECTIVE: To identify information priorities for consumers and clinicians making depression treatment decisions and assess shared decision-making (SDM) in routine depression care. DESIGN: 20 questions related to common features of depression treatments were provided. Participants were initially asked to select which features were important, and in a second stage they were asked to rank their top 5 'important features' in order of importance. Clinicians were asked to provide rankings according to both consumer and clinician perspectives. Consumers completed CollaboRATE, a measure of SDM. Multiple logistic regression analysis identified consumer characteristics associated with CollaboRATE scores. SETTING: Online cross-sectional surveys fielded in September to December 2014. PARTICIPANTS: We administered surveys to convenience samples of US adults with depression and clinicians who treat depression. Consumer sampling was targeted to reflect age, gender and educational attainment of adults with depression in the USA. PRIMARY OUTCOME MEASURES: Information priority rankings; CollaboRATE, a 3-item consumer-reported measure of SDM. RESULTS: 972 consumers and 244 clinicians completed the surveys. The highest ranked question for both consumers and clinicians was 'Will the treatment work?' Clinicians were aware of consumers' priorities, yet did not always prioritise that information themselves, particularly insurance coverage and cost of treatment. Only 18% of consumers reported high levels of SDM. Working with a psychiatrist (OR 1.87; 95% CI 1.07 to 3.26) and female gender (OR 2.04; 95% CI 1.25 to 3.34) were associated with top CollaboRATE scores. CONCLUSIONS: While clinicians know what information is important to consumers making depression treatment decisions, they do not always address these concerns. This mismatch, coupled with low SDM, adversely affects the quality of depression care. Development of a decision support intervention based on our findings can improve levels of SDM and provide clinicians and consumers with a tool to address the existing misalignment in information priorities.

Objectives To demonstrate complementary results of regression and statistical process control (SPC) chart analyses for hospital-acquired pressure ulcers (HAPUs), and identify possible links between changes and opportunities for improvement between hospital microsystems and macrosystems. Methods Ordinary least squares and panel data regression of retrospective hospital billing data, and SPC charts of prospective patient records for a US tertiary-care facility (2004–2007). A prospective cohort of hospital inpatients at risk for HAPUs was the study population. Results There were 337 HAPU incidences hospital wide among 43 844 inpatients. A probit regression model predicted the correlation of age, gender and length of stay on HAPU incidence (pseudo R2=0.096). Panel data analysis determined that for each additional day in the hospital, there was a 0.28% increase in the likelihood of HAPU incidence. A p-chart of HAPU incidence showed a mean incidence rate of 1.17% remaining in statistical control. A t-chart showed the average time between events for the last 25 HAPUs was 13.25 days. There was one 57-day period between two incidences during the observation period. A p-chart addressing Braden scale assessments showed that 40.5% of all patients were risk stratified for HAPUs upon admission. Conclusion SPC charts complement standard regression analysis. SPC amplifies patient outcomes at the microsystem level and is useful for guiding quality improvement. Macrosystems should monitor effective quality improvement initiatives in microsystems and aid the spread of successful initiatives to other microsystems, followed by system-wide analysis with regression. Although HAPU incidence in this study is below the national mean, there is still room to improve HAPU incidence in this hospital setting since 0% incidence is theoretically achievable. Further assessment of pressure ulcer incidence could illustrate improvement in the quality of care and prevent HAPUs.

Enrichment factor (EF) of elements including geo-accumulation indices for soil quality and principal component analysis (PCA) were used to identify the contributions of the origin of sources in the studied area. Results of (40)K, (137)Cs, (238)U and (232)Th including their decay series isotopes in the agricultural soil of Mansa and Bathinda districts in the state of Punjab were presented and discussed. The measured mean radioactivity concentrations for (238)U, (232)Th and (40)K in the agricultural soil of the studied area differed from nationwide average crustal abundances by 51, 17 and 43 %, respectively. The sequence of the EFs of radionuclides in soil from the greatest to the least was found to be (238)U > (40)K > (226)Ra > (137)Cs > (232)Th > (228)Ra. Even though the enrichment of naturally occurring radionuclides was found to be higher, they remained to be in I(geo) class of '0', indicating that the soil is uncontaminated with respect to these radionuclides. Among non-metals, N showed the highest EF and belonged to I(geo) class of '2', indicating that soil is moderately contaminated due to intrusion of fertiliser. The resulting data set of elemental contents in soil was also interpreted by PCA, which facilitates identification of the different groups of correlated elements. The levels of the (40)K, (238)U and (232)Th radionuclides showed a significant positive correlation with each other, suggesting a similar origin of their geochemical sources and identical behaviour during transport in the soil system.

In October 2008, Centers for Medicare and Medicaid Services discontinued reimbursement for hospital-acquired pressure ulcers (HAPUs), thus placing stress on hospitals to prevent incidence of this costly condition.To evaluate whether prevention methods are cost-effective compared with standard care in the management of HAPUs.A semi-Markov model simulated the admission of patients to an acute care hospital from the time of admission through 1 year using the societal perspective. The model simulated health states that could potentially lead to an HAPU through either the practice of "prevention" or "standard care." Univariate sensitivity analyses, threshold analyses, and Bayesian multivariate probabilistic sensitivity analysis using 10,000 Monte Carlo simulations were conducted.Cost per quality-adjusted life-years (QALYs) gained for the prevention of HAPUs.Prevention was cost saving and resulted in greater expected effectiveness compared with the standard care approach per hospitalization. The expected cost of prevention was $7276.35, and the expected effectiveness was 11.241 QALYs. The expected cost for standard care was $10,053.95, and the expected effectiveness was 9.342 QALYs. The multivariate probabilistic sensitivity analysis showed that prevention resulted in cost savings in 99.99% of the simulations. The threshold cost of prevention was $821.53 per day per person, whereas the cost of prevention was estimated to be $54.66 per day per person.This study suggests that it is more cost effective to pay for prevention of HAPUs compared with standard care. Continuous preventive care of HAPUs in acutely ill patients could potentially reduce incidence and prevalence, as well as lead to lower expenditures.

Traces of uranium were measured by laser fluorimeter in 235 subsurface water samples collected from four districts of Punjab state in India. The concentration of U in water samples ranged between

In this study, the concentration of acid and water-soluble ions (Na+, K+, Mg++, Ca++, F−, Cl−, NO3− and SO4− −) in different particle size range (> 1.1– 2.0– 3.3– 4.7– 5.8– 9 μm– Ca++ > K+ > Cl− > F− > Mg++ > NO3− ≈ SO4−−. The average concentration of Na+, K+, Mg++, Ca++, F−, Cl−, NO3− and SO4−− in PM10 aerosols was estimated to be 13.36 g/kg, 3.76 g/kg,0.251 g/kg,3.771 g/kg,0.833 g/kg,1.17 g/kg, 81 μg/kg and 290 μg/kg respectively. The enrichment of particular ion in soluble components may be due to its high abundance in PM10 aerosols, less sorptivity with the tiny solid particles of atmospheric dust, high extractability and leachability, high solubility and mobility. By classifying the PM10 aerosols into two categories viz fine particle ( 2.5 μm–

ObjectiveIf patient engagement is the new ‘blockbuster drug’ why are we not seeing spectacular effects? Studies have shown that activated patients have improved health outcomes, and patient engagement has become an integral component of value-based payment and delivery models, including accountable care organisations (ACO). Yet the extent to which clinicians and managers at ACOs understand and reliably execute patient engagement in clinical encounters remains unknown. We assessed the use and understanding of patient engagement approaches among frontline clinicians and managers at ACO-affiliated practices.DesignQualitative study; 103 in-depth, semi-structured interviews.ParticipantsSixty clinicians and eight managers were interviewed at two established ACOs.ApproachWe interviewed healthcare professionals about their awareness, attitudes, understanding and experiences of implementing three key approaches to patient engagement and activation: 1) goal-setting, 2) motivational interviewing and 3) shared decision making. Of the 60 clinicians, 33 were interviewed twice leading to 93 clinician interviews. Of the 8 managers, 2 were interviewed twice leading to 10 manager interviews. We used a thematic analysis approach to the data.Key resultsInterviewees recognised the term ‘patient activation and engagement’ and had favourable attitudes about the utility of the associated skills. However, in-depth probing revealed that although interviewees reported that they used these patient activation and engagement approaches, they have limited understanding of these approaches.ConclusionsWithout understanding the concept of patient activation and the associated approaches of shared decision making and motivational interviewing, effective implementation in routine care seems like a distant goal. Clinical teams in the ACO model would benefit from specificity defining key terms pertaining to the principles of patient activation and engagement. Measuring the degree of understanding with reward that are better-aligned for behaviour change will minimise the notion that these techniques are already being used and help fulfil the potential of patient-centred care.

A comprehensive study was conducted to determine the soil to plant transfer factor (TFS–P) of K-40, Cs-137, Th-232 and U-238 in perennial plants from accessible areas of Mumbai, using high-resolution γ spectrometry. A total of 50 soil and 150 plants samples were collected from all over the Mumbai region where lithology is dominated by basaltic rocks. The mean concentration values for K-40, Cs-137, Th-232 and U-238 in soil was 170.06 ± 65.36, 5.19 ± 1.20, 25.72 ± 6.262 and 10.21 ± 2.82 Bq kg−1 respectively, whereas in case of plants the mean concentration values were determined to be 181.82 ± 18.50, 0.44 ± 0.14, 0.84 ± 0.19 and 0.79 ± 0.22 Bq kg−1 respectively. The mean activity ratio of Th-232/U-238 in plants is 1.06 while in soil the ratio is 2.5. The soil to plant transfer factor (TFS–P) calculated for K-40, Cs-137, U-238 and Th-232 are 1.05, 0.076, 0.071 and 0.031 respectively. Higher value of TFS–P for K-40, which is an integral part of stable potassium clearly indicates the physiological need of stable potassium, for maintaining the different biological mechanisms of perennial plants under tropical conditions.

Batch experiments were conducted to study the sorption of uranium (U) onto soil in deionised water as a function of its dosage, temperature and humic acid (HA). Furthermore, soils were characterized for particle sizes in the form of sand (>63 µm), silt (>2–

In 2007, the Centers for MedicareMedicaid Services (CMS) announced its intention to no longer reimburse hospitals for costs associated with hospital-acquired pressure ulcers (HAPUs) and a list of other hospital-acquired conditions (HACs), which was followed by enactment of the nonpayment policy in October 2008. This study was conducted to define changes in HAPU incidence and variance since 2008.In a retrospective observational study, HAPU cases were identified at 210 University HealthSystem Consortium (UHC) academic medical centers in the United States. HAPU incidence rates were calculated as a ratio of HAPU cases to the total number of UHC inpatients between the first quarter of 2008 and the second quarter of 2012. HAPU cases were defined by multiple criteria: not present on admission (POA); coded for stage III or IV pressure ulcers; and a length of stay greater than four days.Among the UHC hospitals between 2008 and June 2012, 10,386 HAPU cases were identified among 4.08 million inpatients. The HAPU incidence rate decreased significantly from 11.8 cases per 1,000 inpatients in 2008 to 0.8 cases per 1,000 in 2012 (p.001; 95% confidence interval: 8.39-8.56). Among HAPU cases were trends of more elderly patients, greater case-mix index, and more surgical cases. The analysis of covariance model identified CMS non-payment policy as a significant covariate of changing trends in HAPU incidence rates.HAPU incidence rates decreased significantly among 210 UHC AMCs after the enactment of the CMS nonpayment policy. The hospitals appeared to be reacting efficiently to economic policy incentives by improving prevention efforts.

In 2008, the U.S. Centers for Medicare and Medicaid Services enacted a nonpayment policy for stage III and IV hospital-acquired pressure ulcers (HAPUs), which incentivized hospitals to improve prevention efforts. In response, hospitals looked for ways to support implementation of evidence-based practices for HAPU prevention, such as adoption of quality improvement (QI) interventions. The objective of this study was to quantify adoption patterns of QI interventions for supporting evidence-based practices for HAPU prevention.This study surveyed wound care specialists working at hospitals within the University HealthSystem Consortium. A questionnaire was used to retrospectively describe QI adoption patterns according to 25 HAPU-specific QI interventions into four domains: leadership, staff, information technology (IT), and performance and improvement. Respondents indicated QI interventions implemented between 2007 and 2012 to the nearest quarter and year. Descriptive statistics defined patterns of QI adoption. A t-test and statistical process control chart established statistically significant increase in adoption following nonpayment policy enactment in October 2008. Increase are described in terms of scope (number of QI domains employed) and scale (number of QI interventions within domains).Fifty-three of the 55 hospitals surveyed reported implementing QI interventions for HAPU prevention. Leadership interventions were most frequent, increasing in scope from 40% to 63% between 2008 and 2012; "annual programs to promote pressure ulcer prevention" showed the greatest increase in scale. Staff interventions increased in scope from 32% to 53%; "frequent consult driven huddles" showed the greatest increase in scale. IT interventions increased in scope from 31% to 55%. Performance and improvement interventions increased in scope from 18% to 40%, with "new skin care products . . ." increasing the most.Academic medical centers increased adoption of QI interventions following changes in nonpayment policy. These QI interventions supported adherence to implementation of pressure ulcer prevention protocols. Changes in payment policies for prevention are effective in QI efforts.

Purpose To enhance the learner's competence with knowledge about a framework of quality improvement (QI) interventions to implement evidence-based practices for pressure ulcer (PrU) prevention. Target audience This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. Objectives After participating in this educational activity, the participant should be better able to:1. Summarize the process of creating and initiating the best-practice framework of QI for PrU prevention.2. Identify the domains and QI interventions for the best-practice framework of QI for PrU prevention. Pressure ulcer (PrU) prevention is a priority issue in US hospitals. The National Pressure Ulcer Advisory Panel endorses an evidence-based practice (EBP) protocol to help prevent PrUs. Effective implementation of EBPs requires systematic change of existing care units. Quality improvement interventions offer a mechanism of change to existing structures in order to effectively implement EBPs for PrU prevention. The best-practice framework developed by Nelson et al is a useful model of quality improvement interventions that targets process improvement in 4 domains: leadership, staff, information and information technology, and performance and improvement. At 2 academic medical centers, the best-practice framework was shown to physicians, nurses, and health services researchers. Their insight was used to modify the best-practice framework as a reference tool for quality improvement interventions in PrU prevention. The revised framework includes 25 elements across 4 domains. Many of these elements support EBPs for PrU prevention, such as updates in PrU staging and risk assessment. The best-practice framework offers a reference point to initiating a bundle of quality improvement interventions in support of EBPs. Hospitals and clinicians tasked with quality improvement efforts can use this framework to problem-solve PrU prevention and other critical issues.

Background Hospital-acquired pressure ulcers (HAPUs) are costly to treat and can result in Medicare reimbursement penalties. Statistical models can identify patients at greatest HAPU risk and improve prevention. Objectives To use electronic health record (EHR) data to predict HAPUs among hospitalized patients. Methods EHR data were obtained from an academic medical center that included hospitalized patients with at least 1 skin examination between 2011–2014. These data contained encounter-level demographic variables, diagnoses, prescription drugs and provider orders. HAPUs were defined by stages III, IV or unstageable pressure ulcers not present-on-admission as a secondary diagnosis, and excluded diagnosis of paraplegia/quadriplegia. Random forests and k-means clustering were applied to reduce the dimensionality of the large dataset. A 2-level mixed-effects logistic regression of patient-encounters evaluated associations between covariates and HAPU incidence (Equation 1). Results The approach produced a sample population of 23,054 patients with 1,549 HAPUs. The mixed-effects model predicted HAPUs with exceptional (99%) accuracy for a rare event (table 1). The greatest odds ratio (OR) of HAPU incidence was among patients diagnosed with spinal cord injury (ICD-9 907.2: OR=247.4; P

Article-at-a-Glance Background Prevention of pressure ulcers, one of the hospital-acquired conditions (HACs) targeted by the 2008 nonpayment policy of the Centers for Medicare & Medicaid Services (CMS), is a critical issue. This study was conducted to determine the comparative effectiveness of quality improvement (QI) interventions associated with reduced hospital-acquired pressure ulcer (HAPU) rates. Methods In an quasi-experimental design, interrupted time series analyses were conducted to determine the correlation between HAPU incidence rates and adoption of QI interventions. Among University HealthSystem Consortium hospitals, 55 academic medical centers were surveyed from September 2007 through February 2012 for adoption patterns of QI interventions for pressure ulcer prevention, and hospital-level data for 5,208 pressure ulcer cases were analyzed. Between- and within-hospital reduction significance was tested with t-tests post-CMS policy intervention. Results Fifty-three (96%) of the 55 hospitals used QI interventions for pressure ulcer prevention. The effect size analysis identified five effective interventions that each reduced pressure ulcer rates by greater than 1 case per 1,000 patient discharges per quarter: leadership initiatives, visual tools, pressure ulcer staging, skin care, and patient nutrition. The greatest reductions in rates occurred earlier in the adoption process (p Conclusions Five QI interventions had clinically meaningful associations with reduced stage III and IV HAPU incidence rates in 55 academic medical centers. These QI interventions can be used in support of an evidence-based prevention protocol for pressure ulcers. Hospitals can not only use these findings from this study as part of a QI bundle for preventing HAPUs.