This document summarizes the respiratory staffing needs for a ventilator unit undergoing expansion. It finds that the current staffing of 32 hours per day, or 1.61 hours per patient, is insufficient. Recommended staffing is 3 hours per patient daily. Adding an additional 8 hours of staffing daily from 7am to 11pm would help address spikes in scheduled care needs and allow for more individualized treatment. The current staffing gaps negatively impact care quality and patient outcomes. Increasing staffing is needed to meet patients' clinical needs.
Mahmoud Ma’ani is a mechanical engineer from Jordan with over 4 years of experience in construction projects in Dubai. He has worked as a mechanical engineer and site engineer on projects involving HVAC, plumbing, and mechanical systems design and installation. His experience includes working on projects such as villas, housing complexes, and commercial buildings. He is proficient in AutoCAD, Primavera, and Microsoft Office applications. He is looking for new opportunities as a mechanical engineer in Dubai.
Este documento ofrece consejos sobre la dieta para personas con diabetes. Recomienda una dieta basada en alimentos naturales como frutas, verduras, granos enteros, frijoles y avena. Afirma que seguir esta dieta no solo proporciona una alimentación saludable sino que también puede eliminar la diabetes de manera definitiva. Anima a las personas a hacer clic en un enlace para descubrir este "secreto".
This document analyzes how inequality in Ireland changed during the Great Recession from 2007-2012. It finds that demographic changes and changes in the labor market increased inequality, while changes in market incomes and the tax-benefit system decreased inequality. A decomposition analysis showed that population aging slightly increased inequality, while polarization of employment and a weaker link between education and incomes increased it. However, policy interventions reduced inequality overall. The results also showed variability depending on the order of analysis.
1) According to credit bureau data from 2013, roughly 1 in 20 Americans (5.3%) have debt that is at least 30 days past due. The share varies by region, from 4.6% in the West North Central and Middle Atlantic divisions to 7.5% in the West South Central division.
2) People in the South are more likely to have debt past due compared to other regions. Three states - Louisiana, Texas, and Mississippi - have over 7% of their populations with past due debt.
3) The authors use credit bureau data to analyze patterns of delinquent debt across US states and regions, finding higher rates in the southern states. They aim to better understand financial distress and
Mahmoud Ma’ani is a mechanical engineer from Jordan with over 4 years of experience in construction projects in Dubai. He has worked as a mechanical engineer and site engineer on projects involving HVAC, plumbing, and mechanical systems design and installation. His experience includes working on projects such as villas, housing complexes, and commercial buildings. He is proficient in AutoCAD, Primavera, and Microsoft Office applications. He is looking for new opportunities as a mechanical engineer in Dubai.
Este documento ofrece consejos sobre la dieta para personas con diabetes. Recomienda una dieta basada en alimentos naturales como frutas, verduras, granos enteros, frijoles y avena. Afirma que seguir esta dieta no solo proporciona una alimentación saludable sino que también puede eliminar la diabetes de manera definitiva. Anima a las personas a hacer clic en un enlace para descubrir este "secreto".
This document analyzes how inequality in Ireland changed during the Great Recession from 2007-2012. It finds that demographic changes and changes in the labor market increased inequality, while changes in market incomes and the tax-benefit system decreased inequality. A decomposition analysis showed that population aging slightly increased inequality, while polarization of employment and a weaker link between education and incomes increased it. However, policy interventions reduced inequality overall. The results also showed variability depending on the order of analysis.
1) According to credit bureau data from 2013, roughly 1 in 20 Americans (5.3%) have debt that is at least 30 days past due. The share varies by region, from 4.6% in the West North Central and Middle Atlantic divisions to 7.5% in the West South Central division.
2) People in the South are more likely to have debt past due compared to other regions. Three states - Louisiana, Texas, and Mississippi - have over 7% of their populations with past due debt.
3) The authors use credit bureau data to analyze patterns of delinquent debt across US states and regions, finding higher rates in the southern states. They aim to better understand financial distress and
Lawrence spent the weekend with Poppy, a penguin. On the first day, they enjoyed a cold mango drink and fried fish fillets. On Saturday, Lawrence tried to teach Poppy how to skate, but as a penguin Poppy wanted to teach Lawrence. They then went to the crocodile wetlands with their kitty friend. On Sunday, they played at the park and had a swimming session in the afternoon where Poppy showed off underwater tricks before getting tired. They ended the weekend listening to music before Poppy went to sleep with friends, with Lawrence hoping to see Poppy again soon.
This document contains the resume of Hafiz MD Al-Amin. It summarizes his career objective, highlights, career history and education. His career objective is to work in an environment where he can improve himself and help develop others. His career highlights include strong computer, business development, and public speaking skills. His career history includes roles in trade marketing for Japan Tobacco International and British American Tobacco Bangladesh from 2015 to the present and 2012 to 2014 respectively. He also held internships in 2011. His education includes an MBA and BBA in Marketing.
Jasmine took Poppy on an adventure for a sleepover. Poppy met Jasmine's friends Harrison, Gina, and Zoie. They visited Manly beach, where Poppy said it was similar to where she came from. Poppy, Jasmine, and Harrison enjoyed walking on the rocks and looking at crabs, fish, and shells. They had a yummy breakfast at a Manly café. On Sunday night, Poppy and Zoie became best friends while chilling with Jasmine and Zoie. Jasmine thanks Poppy's mom for letting her take Poppy home, saying they had a great time and Poppy can visit again.
The document provides an overview of the North Carolina System of Care (SOC) for children, youth, and families. It defines SOC as a coordinated network of community-based services and supports that are organized to meet the challenges of children with serious mental health needs and their families. Key aspects of SOC include:
1. Child and Family Teams (CFTs) provide direct services and supports through individualized planning and coordination.
2. Community Collaboratives promote teamwork and system changes at the community level to support CFTs.
3. The State Collaborative works at the state level to identify strengths/issues and support local efforts through relationship building and information sharing.
Families are at
The document discusses emotional intelligence (EQ) and its importance compared to intelligence quotient (IQ). It defines EQ as the ability to perceive, manage, and express emotions, with empathy being a key component. While IQ measures understanding of information, EQ measures understanding of emotions. The document cites sources finding EQ is valued more than IQ for recruiters and in developing skills like communication, negotiation and leadership. It concludes that EQ is important for all jobs that require interacting with and inspiring people.
This document outlines a study on evaluating different techniques for teaching laparoscopic surgery. It begins with an introduction on laparoscopic surgery and its historical development. A literature review is presented on evaluating simulation techniques like virtual reality, box trainers, and animal models. The study aims to assess the educational value of a web-based video training and whether technical skills are improved. The methods section describes a survey of surgeons and trainees to understand perceptions of various teaching methods and preferences. Preliminary results show operating room experience is the most effective but virtual reality is also highly rated.
Ultimate Skills Checklist for Your First Front-End Developer JobBrenna Van Norman
The document provides a skills checklist for becoming a front-end web developer, including essential skills in HTML, CSS, JavaScript, responsive design, frameworks, version control, performance, tools and soft skills. It recommends taking the Front-End Web Developer Nanodegree program or individual courses to learn the skills, and lists additional learning resources like books, newsletters, blogs and communities.
HD Homme is a clothing line founded by self-taught designer Hussein Dhalla in Toronto, Canada. The line aims to distinguish itself through sophisticated designs that embody strength, class, and standing out from the crowd with refinement. HD Homme clothing is meant to allow the wearer to feel as though he owns the night. Contact information and press mentions are also provided.
This document contains the results of a survey given to nursing staff about the current bedside shift reporting process. It shows that the current process takes too long, with the average being 55 minutes per nurse. It also contains redundant information between shifts. The document then outlines the new iNSPIRe bedside reporting process and shows data from testing it. With the new process, the average time per nurse decreased to 13 minutes. This results in over 6,800 hours being freed up for patient care annually between two departments. Patient and staff feedback on the new process has been positive.
The multi-disciplinary team implemented a visual communication board called "Get to Green" to improve team communication and reduce ventilator hours in the MICU. The board displayed the status of parameters needed for extubation for each patient. It was updated every 2 hours and a green checkmark was added when parameters were met. Physicians, nurses and respiratory therapists discussed barriers to extubation daily and weekly dashboards tracked progress. This intervention reduced average ventilator days by 37% from 4.1 to 2.6 days within 10 months and decreased time from meeting criteria to extubation from 82 to 35.4 hours, achieving the project's aims.
Total Joint Replacement- Improving Day of Surgery Efficiency and ThroughputWellbe
Organic growth of total joint replacement volume is growing at 3-4% per year as the number of physicians entering orthopedic residency programs is in decline. Cuts in Medicare reimbursement for total joints is forecast every year producing stressors for the surgeon to perform more surgery just to tread water financially. Increasing surgical volume without increasing time in the day requires a team approach to process improvements. By taking a fresh look at operating room processes, it’s possible to accomplish this goal.
Discussion points include:
• Pre-op patient preparedness
• Resolving inherent conflicts
• Surgical case order
• Tracking case efficiency
• Surgical tray streamlining
About the Speaker:
Sandy Nettrour has specialized in orthopedics for 30 years. She is the Neurosurgery and Orthopedic Service Line Coordinator for Butler Health System, providing oversight of the business aspects of Neurosurgery and Orthopedics, while continuing to first assist in the operating room and provide patient care at the bedside.
Sandy graduated from Alderson Broaddus College in 1980 with a Physician Assistant degree. She has been awarded the Distinguished Fellow Recognition by the American Academy of Physician Assistants, the Hu C. Myers Award for lifetime professional achievement and community service, and the Pennsylvania Society of Physician Assistants Humanitarian of the Year 2013. She was a Round Table Participant in Orthopedics Today June 2012′s “Effective and Efficient Joint Replacement Programs Need Constant Review and Renewal of Processes.”
The document summarizes the current issues with a university student health services primary care clinic. It analyzes the current scheduling system and capacity issues, finding that clinicians were not fully utilized. It then proposes assigning clinicians to teams and improving resource allocation to reduce average patient wait times and increase the rate at which patients see their preferred clinician. Key measures of success are identified as average wait time and the rate of patients seeing their preferred clinician. Recommendations include constructing clinician teams based on hourly patient demand and providing amenities to occupy patients during waits.
1) A healthcare organization was analyzing sources of inefficiency for nurses, finding that 25% of their time was spent "hunting and gathering" or looking for supplies, equipment, information, and assistance from other staff.
2) Further analysis showed that the top things nurses spent time hunting for were medications from the Pyxis machine (8% of hunting time), floor stock equipment like blood pressure cuffs (5.4%), and supplies (3.8%).
3) A "5 whys" analysis was used to determine the root causes for time spent hunting for floor stock electronic equipment, finding issues like equipment not being returned to the proper storage location or being hoarded by other staff for future patients.
This document summarizes the staffing situation for a medical group with the opening of a new facility in Brownsburg. It notes that the group currently has 9 doctors but will need to add hours to cover both existing and new locations. The document considers several options to fill an estimated 330 hour per month gap, such as using existing doctors or hiring locum doctors. It proposes switching to a schedule with 3 physician shifts per day along with additional mid-level providers and scribes, which could save over $300,000 per year while improving coverage and efficiency. Hiring more PAs is recommended to potentially staff the new location's observation unit and inpatient beds.
Safe staffing and productivity through use of technology and professional jud...NHS England
Mike Wright discusses the challenges of ensuring safe nursing staffing levels and effective deployment of resources at Hull Royal Infirmary and Castle Hill Hospital. He outlines how the use of technology, such as an electronic rostering system and the SafeCare software, combined with professional judgement from chief nurses, helps provide real-time visibility into staffing across over 50 wards and 1,200 beds. This integrated approach allows for daily monitoring of staffing levels, patient acuity, and quality metrics to effectively manage staff and address any issues, while also facilitating biannual reviews of nursing establishments.
The document discusses optimization algorithms for planning problems. It begins by introducing Drools Planner, an open source tool for solving planning problems with constraints. It then provides examples of planning problems like employee scheduling and hospital bed planning. These problems involve large search spaces that are intractable to solve via brute force. The document outlines algorithms like construction heuristics, local search, tabu search and simulated annealing that can find high quality solutions in reasonable time by exploring the search space intelligently. It emphasizes the importance of using real-world datasets and constraints to properly evaluate algorithm performance.
This document summarizes an OT utilization review conducted at XYZ Hospital. Key findings include: OT1 utilization was only 53% in 2012 with many surgeries starting late or going past 4pm; orthopedic surgeries made up the majority at 73% despite it being a cardiac-focused hospital; and a study from Sept 2013 found utilization had dropped further to 42% with many starts delayed due to late doctor/patient arrival. Recommendations include reducing non-scheduled hour surgeries, increasing cardiac volumes, and ensuring on-time patient arrival through preparatory work.
Here in this study, my goal is to observe and record the timings of my activities of interest for a period of 20 weekdays and perform the necessary calculations and analysis to find out how and where my time is distributed amongst the activities. From the analysis, it will be possible to find out where time can be redistributed to increase my efficiency and productivity.
1. A study is conducted to estimate survival in patients following.docxjackiewalcutt
1. A study is conducted to estimate survival in patients following kidney transplant. Key factors that adversely affect success of the transplant include advanced age and diabetes. This study involves 25 participants who are 65 years of age and older and all have diabetes. Following transplant, each participant is followed for up to 10 years. The following are times to death, in years, or the time to last contact (at which time the participant was known to be alive).
Deaths: 1.2, 2.5, 4.3, 5.6, 6.7, 7.3 and 8.1 years
Alive: 3.4, 4.1, 4.2, 5.7, 5.9, 6.3, 6.4, 6.5, 7.3, 8.2, 8.6, 8.9, 9.4, 9.5, 10, 10, 10, and 10 years
Use the life table approach to estimate the survival function. Use years intervals of
0–2; 2–4;
Complete the table below.
Interval
in
Years
Number At Risk During Interval,
Nt
Average Number At Risk During Interval,
Nt* =Nt-Ct /2
Number of Deaths During Interval,
Dt
Lost to Follow-Up,
Ct
Proportion Dying
qt= Dt/Nt*
Proportion Surviving
pt= 1-qt
Survival Probability
St= pt*St-1
0–2
2–4
4–6
6–8
8–10
Use the Kaplan-Meier approach to estimate the survival function.
Complete the table below
Referring to the graph above:
What is the probability of surviving 6.5 years?
A. None
B. 0.85
C. 0.60
D. 0.90
Patients have an 85% chance of surviving how many years?
A. 6.0
B. 4.25
C. 3.2
D. 5.5
2. A clinical trial is conducted to evaluate the efficacy of a new drug for prevention of hypertension in patients with pre-hypertension (defined as systolic blood pressure between 120–139 mmHg or diastolic blood pressure between 80–89 mmHg). A total of 20 patients are randomized to receive the new drug or a currently available drug for treatment of high blood pressure. Participants are followed for up to 12 months, and time to progression to hypertension is measured. The experiences of participants in each arm of the trial are shown below.
New Drug
Currently Available Drug
Hypertension
Free of Hypertension
Hypertension
Free of Hypertension
7
8
6
8
8
8
7
9
10
8
9
11
9
10
11
11
11
12
12
12
Estimate the survival (time to progression to hypertension) functions for each treatment group using the Kaplan-Meier approach.
New Drug
Complete the table below.
Time, Months
Number at Risk
Nt
Number of Events (Hypertension)
Dt
Number Censored
Ct
Survival Probability
St+1 = St*((Nt-Dt)/Nt)
Currently Available Drug
Complete the table below.
Time, Weeks
Number at Risk
Nt
Number of Events (Hypertension)
Dt
Number Censored
Ct
Survival Probability
St+1 = St*((Nt-Dt)/Nt)
To answer the question as to whether or not there is a difference in time to progression, a Chi square statistic is computed.The critical value for rejection of the null hypothesis is 3.84. The computed Chi square is 0.335.
Based on comparing the ...
Lawrence spent the weekend with Poppy, a penguin. On the first day, they enjoyed a cold mango drink and fried fish fillets. On Saturday, Lawrence tried to teach Poppy how to skate, but as a penguin Poppy wanted to teach Lawrence. They then went to the crocodile wetlands with their kitty friend. On Sunday, they played at the park and had a swimming session in the afternoon where Poppy showed off underwater tricks before getting tired. They ended the weekend listening to music before Poppy went to sleep with friends, with Lawrence hoping to see Poppy again soon.
This document contains the resume of Hafiz MD Al-Amin. It summarizes his career objective, highlights, career history and education. His career objective is to work in an environment where he can improve himself and help develop others. His career highlights include strong computer, business development, and public speaking skills. His career history includes roles in trade marketing for Japan Tobacco International and British American Tobacco Bangladesh from 2015 to the present and 2012 to 2014 respectively. He also held internships in 2011. His education includes an MBA and BBA in Marketing.
Jasmine took Poppy on an adventure for a sleepover. Poppy met Jasmine's friends Harrison, Gina, and Zoie. They visited Manly beach, where Poppy said it was similar to where she came from. Poppy, Jasmine, and Harrison enjoyed walking on the rocks and looking at crabs, fish, and shells. They had a yummy breakfast at a Manly café. On Sunday night, Poppy and Zoie became best friends while chilling with Jasmine and Zoie. Jasmine thanks Poppy's mom for letting her take Poppy home, saying they had a great time and Poppy can visit again.
The document provides an overview of the North Carolina System of Care (SOC) for children, youth, and families. It defines SOC as a coordinated network of community-based services and supports that are organized to meet the challenges of children with serious mental health needs and their families. Key aspects of SOC include:
1. Child and Family Teams (CFTs) provide direct services and supports through individualized planning and coordination.
2. Community Collaboratives promote teamwork and system changes at the community level to support CFTs.
3. The State Collaborative works at the state level to identify strengths/issues and support local efforts through relationship building and information sharing.
Families are at
The document discusses emotional intelligence (EQ) and its importance compared to intelligence quotient (IQ). It defines EQ as the ability to perceive, manage, and express emotions, with empathy being a key component. While IQ measures understanding of information, EQ measures understanding of emotions. The document cites sources finding EQ is valued more than IQ for recruiters and in developing skills like communication, negotiation and leadership. It concludes that EQ is important for all jobs that require interacting with and inspiring people.
This document outlines a study on evaluating different techniques for teaching laparoscopic surgery. It begins with an introduction on laparoscopic surgery and its historical development. A literature review is presented on evaluating simulation techniques like virtual reality, box trainers, and animal models. The study aims to assess the educational value of a web-based video training and whether technical skills are improved. The methods section describes a survey of surgeons and trainees to understand perceptions of various teaching methods and preferences. Preliminary results show operating room experience is the most effective but virtual reality is also highly rated.
Ultimate Skills Checklist for Your First Front-End Developer JobBrenna Van Norman
The document provides a skills checklist for becoming a front-end web developer, including essential skills in HTML, CSS, JavaScript, responsive design, frameworks, version control, performance, tools and soft skills. It recommends taking the Front-End Web Developer Nanodegree program or individual courses to learn the skills, and lists additional learning resources like books, newsletters, blogs and communities.
HD Homme is a clothing line founded by self-taught designer Hussein Dhalla in Toronto, Canada. The line aims to distinguish itself through sophisticated designs that embody strength, class, and standing out from the crowd with refinement. HD Homme clothing is meant to allow the wearer to feel as though he owns the night. Contact information and press mentions are also provided.
This document contains the results of a survey given to nursing staff about the current bedside shift reporting process. It shows that the current process takes too long, with the average being 55 minutes per nurse. It also contains redundant information between shifts. The document then outlines the new iNSPIRe bedside reporting process and shows data from testing it. With the new process, the average time per nurse decreased to 13 minutes. This results in over 6,800 hours being freed up for patient care annually between two departments. Patient and staff feedback on the new process has been positive.
The multi-disciplinary team implemented a visual communication board called "Get to Green" to improve team communication and reduce ventilator hours in the MICU. The board displayed the status of parameters needed for extubation for each patient. It was updated every 2 hours and a green checkmark was added when parameters were met. Physicians, nurses and respiratory therapists discussed barriers to extubation daily and weekly dashboards tracked progress. This intervention reduced average ventilator days by 37% from 4.1 to 2.6 days within 10 months and decreased time from meeting criteria to extubation from 82 to 35.4 hours, achieving the project's aims.
Total Joint Replacement- Improving Day of Surgery Efficiency and ThroughputWellbe
Organic growth of total joint replacement volume is growing at 3-4% per year as the number of physicians entering orthopedic residency programs is in decline. Cuts in Medicare reimbursement for total joints is forecast every year producing stressors for the surgeon to perform more surgery just to tread water financially. Increasing surgical volume without increasing time in the day requires a team approach to process improvements. By taking a fresh look at operating room processes, it’s possible to accomplish this goal.
Discussion points include:
• Pre-op patient preparedness
• Resolving inherent conflicts
• Surgical case order
• Tracking case efficiency
• Surgical tray streamlining
About the Speaker:
Sandy Nettrour has specialized in orthopedics for 30 years. She is the Neurosurgery and Orthopedic Service Line Coordinator for Butler Health System, providing oversight of the business aspects of Neurosurgery and Orthopedics, while continuing to first assist in the operating room and provide patient care at the bedside.
Sandy graduated from Alderson Broaddus College in 1980 with a Physician Assistant degree. She has been awarded the Distinguished Fellow Recognition by the American Academy of Physician Assistants, the Hu C. Myers Award for lifetime professional achievement and community service, and the Pennsylvania Society of Physician Assistants Humanitarian of the Year 2013. She was a Round Table Participant in Orthopedics Today June 2012′s “Effective and Efficient Joint Replacement Programs Need Constant Review and Renewal of Processes.”
The document summarizes the current issues with a university student health services primary care clinic. It analyzes the current scheduling system and capacity issues, finding that clinicians were not fully utilized. It then proposes assigning clinicians to teams and improving resource allocation to reduce average patient wait times and increase the rate at which patients see their preferred clinician. Key measures of success are identified as average wait time and the rate of patients seeing their preferred clinician. Recommendations include constructing clinician teams based on hourly patient demand and providing amenities to occupy patients during waits.
1) A healthcare organization was analyzing sources of inefficiency for nurses, finding that 25% of their time was spent "hunting and gathering" or looking for supplies, equipment, information, and assistance from other staff.
2) Further analysis showed that the top things nurses spent time hunting for were medications from the Pyxis machine (8% of hunting time), floor stock equipment like blood pressure cuffs (5.4%), and supplies (3.8%).
3) A "5 whys" analysis was used to determine the root causes for time spent hunting for floor stock electronic equipment, finding issues like equipment not being returned to the proper storage location or being hoarded by other staff for future patients.
This document summarizes the staffing situation for a medical group with the opening of a new facility in Brownsburg. It notes that the group currently has 9 doctors but will need to add hours to cover both existing and new locations. The document considers several options to fill an estimated 330 hour per month gap, such as using existing doctors or hiring locum doctors. It proposes switching to a schedule with 3 physician shifts per day along with additional mid-level providers and scribes, which could save over $300,000 per year while improving coverage and efficiency. Hiring more PAs is recommended to potentially staff the new location's observation unit and inpatient beds.
Safe staffing and productivity through use of technology and professional jud...NHS England
Mike Wright discusses the challenges of ensuring safe nursing staffing levels and effective deployment of resources at Hull Royal Infirmary and Castle Hill Hospital. He outlines how the use of technology, such as an electronic rostering system and the SafeCare software, combined with professional judgement from chief nurses, helps provide real-time visibility into staffing across over 50 wards and 1,200 beds. This integrated approach allows for daily monitoring of staffing levels, patient acuity, and quality metrics to effectively manage staff and address any issues, while also facilitating biannual reviews of nursing establishments.
The document discusses optimization algorithms for planning problems. It begins by introducing Drools Planner, an open source tool for solving planning problems with constraints. It then provides examples of planning problems like employee scheduling and hospital bed planning. These problems involve large search spaces that are intractable to solve via brute force. The document outlines algorithms like construction heuristics, local search, tabu search and simulated annealing that can find high quality solutions in reasonable time by exploring the search space intelligently. It emphasizes the importance of using real-world datasets and constraints to properly evaluate algorithm performance.
This document summarizes an OT utilization review conducted at XYZ Hospital. Key findings include: OT1 utilization was only 53% in 2012 with many surgeries starting late or going past 4pm; orthopedic surgeries made up the majority at 73% despite it being a cardiac-focused hospital; and a study from Sept 2013 found utilization had dropped further to 42% with many starts delayed due to late doctor/patient arrival. Recommendations include reducing non-scheduled hour surgeries, increasing cardiac volumes, and ensuring on-time patient arrival through preparatory work.
Here in this study, my goal is to observe and record the timings of my activities of interest for a period of 20 weekdays and perform the necessary calculations and analysis to find out how and where my time is distributed amongst the activities. From the analysis, it will be possible to find out where time can be redistributed to increase my efficiency and productivity.
1. A study is conducted to estimate survival in patients following.docxjackiewalcutt
1. A study is conducted to estimate survival in patients following kidney transplant. Key factors that adversely affect success of the transplant include advanced age and diabetes. This study involves 25 participants who are 65 years of age and older and all have diabetes. Following transplant, each participant is followed for up to 10 years. The following are times to death, in years, or the time to last contact (at which time the participant was known to be alive).
Deaths: 1.2, 2.5, 4.3, 5.6, 6.7, 7.3 and 8.1 years
Alive: 3.4, 4.1, 4.2, 5.7, 5.9, 6.3, 6.4, 6.5, 7.3, 8.2, 8.6, 8.9, 9.4, 9.5, 10, 10, 10, and 10 years
Use the life table approach to estimate the survival function. Use years intervals of
0–2; 2–4;
Complete the table below.
Interval
in
Years
Number At Risk During Interval,
Nt
Average Number At Risk During Interval,
Nt* =Nt-Ct /2
Number of Deaths During Interval,
Dt
Lost to Follow-Up,
Ct
Proportion Dying
qt= Dt/Nt*
Proportion Surviving
pt= 1-qt
Survival Probability
St= pt*St-1
0–2
2–4
4–6
6–8
8–10
Use the Kaplan-Meier approach to estimate the survival function.
Complete the table below
Referring to the graph above:
What is the probability of surviving 6.5 years?
A. None
B. 0.85
C. 0.60
D. 0.90
Patients have an 85% chance of surviving how many years?
A. 6.0
B. 4.25
C. 3.2
D. 5.5
2. A clinical trial is conducted to evaluate the efficacy of a new drug for prevention of hypertension in patients with pre-hypertension (defined as systolic blood pressure between 120–139 mmHg or diastolic blood pressure between 80–89 mmHg). A total of 20 patients are randomized to receive the new drug or a currently available drug for treatment of high blood pressure. Participants are followed for up to 12 months, and time to progression to hypertension is measured. The experiences of participants in each arm of the trial are shown below.
New Drug
Currently Available Drug
Hypertension
Free of Hypertension
Hypertension
Free of Hypertension
7
8
6
8
8
8
7
9
10
8
9
11
9
10
11
11
11
12
12
12
Estimate the survival (time to progression to hypertension) functions for each treatment group using the Kaplan-Meier approach.
New Drug
Complete the table below.
Time, Months
Number at Risk
Nt
Number of Events (Hypertension)
Dt
Number Censored
Ct
Survival Probability
St+1 = St*((Nt-Dt)/Nt)
Currently Available Drug
Complete the table below.
Time, Weeks
Number at Risk
Nt
Number of Events (Hypertension)
Dt
Number Censored
Ct
Survival Probability
St+1 = St*((Nt-Dt)/Nt)
To answer the question as to whether or not there is a difference in time to progression, a Chi square statistic is computed.The critical value for rejection of the null hypothesis is 3.84. The computed Chi square is 0.335.
Based on comparing the ...
This document provides guidelines and procedures for in-office vision therapy for the treatment of amblyopia. It outlines three phases of therapy focusing on accommodation, suppression, and vergence skills. Each phase builds upon the previous with increasing difficulty of activities. Specific procedures are described for each treatment category within each phase. Therapists are instructed to choose activities to target all three areas at each visit while progressing patients through the phases based on achieving outlined endpoints. Detailed instructions are given for administering procedures and advancing therapy.
This document provides guidelines and procedures for in-office vision therapy for the treatment of amblyopia. It outlines qualifications for vision therapists, general protocols for therapy including weekly 60-minute visits over 16 weeks, and sequencing of procedures from easiest to hardest over three phases of therapy. The procedures are divided into categories of accommodation, vergence, and suppression therapy. Specific activities are described for each category within each phase.
This document provides guidelines and procedures for in-office vision therapy for the treatment of amblyopia. It outlines qualifications for vision therapists, general protocols for therapy including weekly 60-minute visits over 16 weeks, and sequencing of procedures from easiest to hardest over three phases of therapy. The procedures are divided into categories of accommodation, vergence, and suppression therapy. Specific activities are described for each category within each phase.
The document discusses a patient-centered approach to treating angina that focuses on involving patients and caregivers in developing care plans. Studies found this approach improved quality of life and reduced angina symptoms, hospital admissions, and demand for procedures compared to traditional treatment. Patients and caregivers reported benefits like reduced anxiety and valued being listened to in developing individualized care plans that met their needs and priorities.
The document discusses new changes to the USMLE Step 3 Clinical Case Simulations (CCS) component starting in February 2012, including fewer cases with longer times and more cases with shorter times. It provides tips on prioritizing tasks, sequencing orders, and monitoring patients in CCS cases. Key areas that are scored include diagnosis, location, timing, sequencing, and monitoring of patients. Guidance is given on stabilizing patients in emergency settings and managing conditions like shock, respiratory failure, and sepsis.
Place Cell Mapping and Stress Monitoring in Head-Fixed Mice Navigating an Air...InsideScientific
In this webinar sponsored by Neurotar, experts present their research on 2-photon imaging of hippocampal place cells and on stress monitoring in head-fixed awake behaving mice. Dr. Konrad Juczewski from the National Institutes of Health (NIH)/National Institute on Alcohol Abuse and Alcoholism (NIAAA) discusses the impact of head fixation on animal’s stress, locomotion and performance in classical behavioral paradigms.
Dr. Mary Ann Go from the Laboratory of Neural Coding and Neurodegenerative Disease at Imperial College London led by Prof. Simon Schultz presents her research using 2-photon microscopy aimed at place cell mapping in the hippocampus during exploration and navigation of a circular linear track.
Key Discussion Topics Include:
- Stress reduction in head-fixed rodents
- Improving data reproducibility and translational value of the data acquired from head-fixed rodents
- Effects of head fixation on blood corticosterone concentration, locomotion patterns and performance in stress-associated behavioral tests
- Optimizing habituation protocol for head-fixed mice
- Monitoring neural activity and mapping of place cells using 2-photon microscopy during navigation and exploration behavior
- Automating the experiments using a closed-loop approach and behavior-triggered reward systems
2. How do we currently staff?
- Each day we currently can provide:
- 1x Day Shift
- 7am – 7pm
- 12 Hours
- 1x Night Shift
- 7pm – 7am
- 12 Hours
- 1x “Swing Shift”
- 1pm – 9pm
- 8 Hours
- …for a total of 32 hours per day.
3. Is this enough?
32 Hours divided between our average of 14 patients gives us 2.28 hours per day per patient, not
including documentation.
Documentation requires, on average, 20 minutes per patient per shift. So, 40 minutes per patient at 14
patients means 9.33 hours per day are spent documenting.
32 hours minus 9.33 hours equals an actual total of 22.67 is available for actual patient care.
The adjusted 22.67 hours divided between 14 patients gives us 1.61 hours per patient per day.
RHS recommends staffing to meet the needs of each patient at an adjusted estimated 3 hours of labor
per patient per day. 1.61 hours is just over half of that.
The AARC and NBRC both recommend staffing 1 RT for every 8 ventilators. At 1.3:14 RT to Ventilator
ratio we are just under 60% of the way there.
4. Wait, there’s more!
Let’s take our 1.61 hours available per patient per day and subtract our routine care.
Routine care includes mandatory vent checks, tracheostomy care, and assessments.
A stable vent or tracheostomy patient with no scheduled treatments will require, at a
bare minimum and done very quickly:
[1] 4x Ventilator Checks and Assessments for 40 Minutes of Labor.
[2] 2x Routine Tracheostomy Tube Care Sessions for 20 Minutes of Labor
Each patient, as soon as they are admitted, will immediately have 60 minutes of labor
as standing, routine orders.
Subtract 1 hour from our available 1.61 hours and we are left with 0.61 hours per
patient per day.
This is just under 37 minutes available per patient per day.
5. But, our patient’s also need other stuff?
Yes, they do!
Scheduled Treatments
Most of our ventilator dependent and tracheostomy patients will have respiratory
treatment orders ranging from nebulizer treatments and inhalers to intensive
specialty therapies like Chest Physiotherapy, pulmonary toileting, and weaning
trials. Nebulizer treatments take around 10 minutes to administer while weaning
and more involved therapies can have our RTs with a patient for up to an hour.
As Needed Interventions
The AARC concluded that “PRN” interventions can account for over 40% of an
RT’s daily routine. Every request for suctioning, ventilator troubleshooting,
oxygen adjustments, emergent assessments, and even something as simple as
getting a patient ready to travel for a shower or trip to the gym takes time.
6. 15 Patients Under RT Care
9 Have Scheduled Treatments
2 Require Weaning Therapy
3 Require Specialty Therapy
All Require PRN Interventions
7. 290 minutes of scheduled
treatments per day.
110 Minutes are scheduled to
be completed between 8am
and 10 am (120 Minutes)
8. 290 minutes of scheduled
treatments per day.
110 Minutes are scheduled to
be completed between 8am
and 10 am (120 Minutes)
120 Minutes of scheduled
specialty care per day…
Between only 2 patients.
9. 290 minutes of scheduled
treatments per day.
110 Minutes are scheduled to
be completed between 8am
and 10 am (120 Minutes)
120 Minutes of scheduled
specialty care per day…
Between only 2 patients.
Add our standing routine care
and there is now 225 minutes of
labor that is due in a 120
minute period!
10. What type of patient presents the largest challenge
and most amount of labor?
Ventilator and non-vent tracheostomy, believe it or now, have
very similar needs from an operation standpoint. Acuity is based
more on clinical status, medical condition, and mental status.
From “least” to “most” labor:
[1] Chronic, stable, persistent vegetative patients.
[2] Chronic stable and alert patients.
[3] Weanable patients.
[4] Chronic unstable patients.
However individual patients may defy this list. There will be
medically stable chronic patients who make unreasonable
demands, are abusing the call-bell, or have behavioral issues that
demand more attention.
11. The patient on this list who has the
largest amount of scheduled labor is a
non-vent tracheostomy patient…
His scheduled treatment and
intervention routine consumes almost 4
hours a day.
The next most labor-intensive patient,
a weanable ventilator, consumes just
under 2 hours a day…
16. 0
0.5
1
1.5
2
2.5
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Time Available per Patient per Day
Time Available Per Patient (Ta = aL/C) Actual Time Available Per Patient (aTa = StA/C)
17. 0
10
20
30
40
50
60
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
All Values
Vent & Trach Census (C) Expected Labor Per Day (eL) Scheduled Labor Per Day (sL = 3*C)
Unscheduled Labor Provided (uL = Acutal Value) Actual Labor Provided (aL = Actual Value) Scheduled Time Actually Available (StA = aL-uL)
Time Available Per Patient (Ta = aL/C) Actual Time Available Per Patient (aTa = StA/C)
18. 0
10
20
30
40
50
60
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
All Values
Vent & Trach Census (C) Expected Labor Per Day (eL) Scheduled Labor Per Day (sL = 3*C)
Unscheduled Labor Provided (uL = Acutal Value) Actual Labor Provided (aL = Actual Value) Scheduled Time Actually Available (StA = aL-uL)
Time Available Per Patient (Ta = aL/C) Actual Time Available Per Patient (aTa = StA/C)
Sometimes we have more labor
SCHEDULED than labor available!
19. 0
5
10
15
20
25
30
35
40
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Scheduled Labor vs. Actual Time Available
Scheduled Labor Per Day (sL = 3*C) Scheduled Time Actually Available (StA = aL-uL)
Never did we have enough
time to provide our scheduled
labor as scheduled…
20. So, how are we doing it now?
The short answer is that we don’t.
Treatments are sometimes missed and often provided late.
Our documentation quality and completion has suffered.
A “bare minimum” attitude to all aspects of care is assumed.
Increased sick calls are seen.
Decreased patient satisfaction has been noted.
Increased wait times on all patient requests.
Worse outcomes especially for weanable patients.
A lack of personal and individualized care…
21. What’s the solution?
Additional Regular Staff
While attempting to staff to RHS expected labor of 3 hours per
patient per day would mean often having 2 RTs on all day every
day, there is an 8 hour period of time when having one RT on is
okay from an expected labor standpoint.
Adding 8 hours per day will go a long way to maintaining the
quality of care and positive outcomes we would like to be
known for.
Having 2 RTs scheduled from 7am until 11pm makes primary
morning and evening rounds doable without defying the laws of
physics. Weaning and specialty care items can be completed in
a timely and comprehensive manner as having an RT spend
extended periods of time with a single patient would no longer
be impossible.
Having 2 RTs also decreases the impact of sick calls.
26. The “New” Staffing Plan
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 0 1 2 3 4 5 6
Scheduled Labor Number of RTs
Day Shift 7a – 7p = 12H
Day Supplement 7a – 3p = 8H
Evening Shift 3p – 11p = 8H
Night Shift 7p – 7a = 12H
40 Total Hours Per Day
Results in 2 RTs from 7am until 11pm.
27. Alternative and Additional Strategies
Delineation of routine PRN care…
-Treat the RT staff more like an acute care hospital treats their RT department.
- RTs do their scheduled routine rounds and are only called for specialty needs.
- Vent changes, troubleshooting, non-nursing scope activities…
- A Coventry RT will do more suctioning in a week than an MGH ICU RT will do in a year…
- Most RT departments stage in a separate office and carry pagers or cellphones
responding to PRN requests that exceed the scope of nursing.
Admission criteria shifts to accept only more “low-impact” patients…
- Stable persistent vegetative patients do not impact labor unexpectedly.
Implement a limited scheduled treatment expectation…
- CPT sessions, pulmonary toileting, extended weaning or PMV trials can add hours.
Defy RHS documentation and assessment frequency policies…
- Decreasing the amount of repetitive treatment and assessment notes could free up hours
per day for patient care.
28. Other Considerations
Nursing Education
- The floors have relied on out vent unit RTs for routine matters for too long.
- Nasal cannula retrieval and oxygen concentrator troubleshooting for 1 North is
not what you want to pay your RTs for.
CNA Education
- Most of our stoma trauma and tube dislodgements are caused by poor circuit
etiquette during patient repositioning and daily activities.
- A formulaic and regimented educational seminar refreshed regularly will go a long
towards decreasing the number of PRN interventions your RTs need to respond to.
A Different Look at Acuity Upon Admission
- Sicker patients require more time, will be sent back to the hospital more often,
and are going to have poorer outcomes.
- Attracting more “cardiac” patients will bring in patients of a higher acuity.
- The heart and lungs have a symbiotic relationship. Bad hearts almost always means
breathing troubles. Be prepared to see more BiPAPs, higher O2 usage, and more
respiratory distress noted.
29. Moving Forward
Everything outside of the ventilator unit is considered “PRN” by RHS. The moment a large
percentage of that patient population is demanding regular respiratory services is the moment
that “PRN” label needs to go away. Certain floors, especially the 2nd floor, may need to be seen
as requiring regular respiratory labor.
Regular scheduled respiratory care may benefit the entire building.
Currently 8 – 12 hours a week can be spent on the floors assessing patients, setting up BiPAPs,
doing home-care qualification procedures, troubleshooting machines, and even patient and
family education. Often 12 hours can be achieved while actively seeking to avoid floor labor…
The process now, however, is ad-hoc and without structure. Services are regularly rendered last-
minute or hours after a new patient arrives and there is a surprise CPAP order that wasn’t in the
admission packet. Frantic RNs find their way to the ventilator unit and pull the RT off the floor
for everything from basic supply requisition to emergent issue assessment.
Although things seem better than in the days of the “hotline”, structure is badly needed.
30. Alas, in the end…
We have reached, and been atop, a tipping point since being able to maintain
a census of over 12 patients over the last 16 months.
If our vent unit wants to expand, focus on weanable patients, function within
a “cardiac branding”, and still provide timely high-quality care, our RTs will
need to have the time to work.
At 40 hours of regular labor per day timely comprehensive care of up to 18
ventilator and tracheostomy patients of varying acuities will be possible.
Even though this will still put us way under the mark for the RHS calculated
labor, sitting at a 9:1 vent to RT ratio for 66% of the day is much better than
what we achieve currently.