The purpose of this thesis was to determine the feasibility of implementing an intervention tailored to overcome barriers to adherence to recommendations of critical care nutrition guidelines in the Intensive Care Unit (ICU). The thesis is comprised of four manuscripts. The first manuscript described the development of a 26 item questionnaire rating the importance of potential barriers as impediments to the provision of enteral nutrition (EN) in the ICU. Preliminary evaluation demonstrated acceptable face and content validity and internal reliability, but the test retest reliability and within group reliability were poor for some items. The second manuscript provided evidence to support the construct validity of the developed questionnaire by reporting the results of a multilevel multivariate regression analysis of cross-sectional data from 55 ICUs that demonstrated that a 10 point increase in the overall barrier score was associated with a statistically significant 3.5% (Standard Error (SE) 1.3) decrease in prescribed calories received from EN. The third manuscript provided data to inform whether the intervention should be tailored to site specific barriers by describing the barriers to enterally feeding critically ill patients identified by 138 nurses, and evaluating whether these barriers differed across the 5 participating sites. Statistically significant differences were found among ICUs for 4 out of the 22 potential barriers. The fourth manuscript described the results of a pretest posttest study involving 5 ICUs in North America and determined that all participating sites successfully developed the tailored intervention. A statistically significant 10% (Site range -4.3 to -26.0%) decrease in overall barriers score, and a non-significant 6% (Site range -1.5 to17.9%) change in prescribed calories received was observed following the intervention. However, there was variability in the degree of implementation achieved by each site. Taken together, the results of this thesis demonstrated that adopting a tailored approach to improving nutrition practice is feasible. However, the findings also resulted in revisions to the barriers questionnaire and modifications to the design of the tailored intervention. Thus, the next step is to formally test the hypothesis that a tailored intervention designed to address barriers to feeding critically ill patients will improve nutrition performance. / Thesis (Ph.D, Community Health & Epidemiology) -- Queen's University, 2013-04-28 21:37:54.695

En svårt sjuk patient som vårdas på en intensivvårdsavdelning, med svikt i ett eller flera organsystem, löper betydande risk att drabbas av malnutrition med ökad risk för infektioner och längre vårdtider. När en väl utarbetad riktlinje inom nutrition följs ökar patientens möjligheter att nå upp till sitt kalorimål med minskad malnutrition och förkortade vårdtider som följd. Syftet med studien var att undersöka följsamheten till en befintlig riktlinje om nutrition på en intensivvårdsavdelning i västra Sverige med hjälp av journalgranskning. Ett konsekutivt urval gjordes och 31 uppfyllde inklusionskriterierna. Journalerna granskades enligt deskriptiv analys. Resultatet visade en varierande följsamhet till riktlinjen med högst följsamhet mot slutet av vårdtiden och lägst följsamhet i början av vårdtiden. Med hjälp av resultatet i denna studie kan följsamheten till riktlinjen förbättras och på så sätt kan bedömning och behandling av nutrition för intensivvårdspatienten optimeras. / A critically ill patient within the intensive care unit, with failure in one or more organ systems, has an increased risk of malnutrition with infections and extended hospital stay as a result. When a wellestablished guideline of nutrition is used, the patients possibility of reaching the caloric goal increases which lead to decreased malnutrition and shortened hospital stay. The aim of the study was to investigate the compliance of an enteral and parenteral guideline in an intensive care unit in a hospital in the west of Sweden with a review of medical records. A consecutive sample was made and 31 patients met the criteria. The medical records were reviewed according to descriptive analysis. The results showed a varying compliance to the guideline, with the highest compliance in the end of hospital stay and the lowest compliance in the beginning of hospital stay. Using the results in this study, the compliance of the nutritional guideline can be improved, and nutritional assessment and treatment for the intensive care patient can be optimized.

This aim of the research was to explore pharmacist prescribing (PP) with a focus on antimicrobials, in hospitals in Scotland. A mixed-methods approach was used to collect, generate and synthesise data. A systematic review of peer-reviewed published literature on evidence-based roles for the pharmacist as part of an antimicrobial multidisciplinary team, identified roles for pharmacists within the teams but limited evidence relating to outcomes associated with these roles. Six qualitative focus groups, with 37 hospital pharmacists in 5 Scottish Health Boards, contextualised perceptions of barriers to, and facilitators of, implementation of PP in hospitals. Key themes were: perceived lack of pharmacy management support to take on a prescribing role and little strategic attention paid to PP implementation and sustainability. These issues were discussed in relation to PP in general and not only for antimicrobials. Participants perceived successful implementation of PP to be associated with factors including ward type and patient’s clinical condition. None of the pharmacists were prescribing antimicrobials and consequently further studies focused on PP in general. A scoping exercise, utilising various sources of information, reinforced findings from Phase 1; it highlighted the absence of any national or Health Board frameworks to support implementation of PP in secondary care in Scotland. Consensus-based research was undertaken, therefore, to provide guidance to facilitate service redesign involving PP in secondary care in Scotland. A Delphi approach undertaken with 40 experts, mainly in strategic posts, resulted in a high level of agreement in areas relating to succession planning, rather than role development; more variability was obtained in areas relating to future orientation of service, competencies required by prescribers and potential development of non-medical prescribing teams. The guidance was developed into a self-assessment toolkit providing an analytical strategy for implementation and role development of PP in secondary care. While the results and conclusions generated through this research need to be interpreted with caution, the data generated is an original contribution to the evidence base relating to PP.

Introduction. The high technology environment such as a radiology and anaesthesia department in a typical health care setting can many times be a frightening environment for children. Children with neurodevelopmental disorders, such as Autism Spectrum Disorder (ASD), have problems with communication and social interaction. They are dependent on routines and can have higher sensitivity to sensory stimuli than other children. These children are one group who constitutes special challenges in reducing anxiety and creating participation in a high technology environment. This can make them prone to frightening encounters in health care settings if not cared for with special consideration. Aim: The overall aim of this thesis was to audit and enhance the care of children in a high technology environment in the health care system with a focus on children with Autism Spectrum Disorder. Methods: A descriptive design was used with both qualitative and quantitative methods. In Study I, 32 nurse anaesthetists were interviewed to explore the actions and experiences of caring for children in a high technology environment using a qualitative method, known as the Critical Incident Technique (CIT). In the two following studies (Study II, III) a cross-sectional design was used and two national surveys were performed to obtain knowledge on the status in Sweden regarding the care of children with ASD in high technology environments. Sixty-eight anaesthesia departments, 38 paediatric departments and 86 radiology departments responded to the survey. Descriptive statistic was used for the answers apart from the comments part of the questionnaire where qualitative content analysis was used. Due to the limited existence of guidelines in these environments, the creation ofevidence-based guidelines was performed in Study IV, using a Delphi method. The Delphi study was based on information gleaned from the previous studies and from the literature, and 21 experts identified in Study II and III were the expert panel developing the guidelines. Result: Nurses identified children with special needs such as children with ASD as a vulnerable group in a high technology environment (Study I). Seven departments in the anaesthesia context had guidelines for caring for children with ASD in the perioperative context. In the other departments, the care of children with ASD was dependent on the knowledge of the nurse presently working there (Study II). None of the radiology departments in Sweden had guidelines on how to care for children with ASD going through a radiographic examination without anaesthesia (Study III). As a result of Study I, II and III, the need for structured guidelines for caring for children with ASD in a high technology context was identified and a set of guidelines and a checklist was created. The guidelines relate to the organisational structure for the care of children with deficits in social interaction, communication, sensory sensitivity and dependence on routines. The checklist relates to gleaning information about the specific child to be able to give person-centred care based on the specific characteristic of the child (Study IV). Conclusion: Nurses working in a high technology environment in health care have diverse experiences of preventing anxiety in children with ASD coming for a challenging procedure. There are a limited number of evidence-based guidelines to decrease anxiety and to create participation in this group ofchildren. Evidence-based guidelines were created as a tool for enhancing person-centred care in a high technology environment for this group of children. The fact that several problems are assembled under one disorder makes ASD a useful condition to have as a basis for formulating national guidelines. Guidelines that cater for the care of children with ASD in a high technology environment using a person-centred approach may also extend to the care for children with other neurodevelopmental disorders that exhibit some of the same problems as children with ASD.

The problem involved in this study was twofold. The first was to ascertain what the employment requirements were for a person seeking employment in the field 6f electronics as a technician in the Dallas Metropolitan Area. The second was to determine what the job opportunities were for those individuals.

Title: Analysis of Pharmacotherapy by patients with diagnosis of COPD Student: Marilena Kartali-Kaouni Tutor: Prof. RNDr. Jiri Vlcek, CSc Department of Social and Clinical Pharmacy, Charles University in Prague, Faculty of Pharmacy in Hradec Kralove Background: " Chronic Obstructive Pulmonary Disease (COPD) is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases". Tobacco smoking is the major risk factor in the development of COPD. COPD is a leading cause of morbidity and mortality worldwide. Aim: 1st from the current literature to understand the nature of COPD and obtain information about the aetiopathogenesis of the disease, diagnosis options and summarize the current view of strategies for achieving the goals of treatment. 2nd in a pilot study to analyze drug therapy in COPD patients visiting a pharmacy in Greece. Methods: 56 prescriptions with the diagnosis of COPD were collected during a period of 8 months from a Greek pharmacy. Information from the prescriptions with regard to COPD medications prescribed (active substances, trade names, strength, dosage scheme, pack size), patients characteristics (age and gender) and prescribing...

Master of Landscape Architecture / Department of Landscape Architecture/Regional and Community Planning / Blake Belanger / Anticipating a thirty five percent population increase over the next thirty years, the Mid-America Regional Council (MARC) developed the Creating Sustainable Places: A Regional Plan for Sustainable Development in Greater Kansas City (CSP) as a comprehensive strategy to guide the Greater Kansas City Metropolitan Region (KC Metro) to grow sustainably into the future. The Rock Island Corridor (RIC) is one of six key corridors identified by the Smart Moves Regional Transit Vision Alternatives Analysis to be redeveloped with the first phase extending seventeen miles from Downtown Kansas City, MO to Pleasant Hill, MO. Phase one will include a mixed use trail and commuter rail line with the second phase planning to extend the mixed use trail to Windsor, MO; becoming the primary link between the KC Metro and the 238 mile long Missouri Katy Trail State Park. Reactivating the RIC, having zero gateways and untouched for thirty years, suggests the corridor communities will require a true collaboration to develop the gateways as destinations at the proposed commuter rail stations. Involving an artist(s) with the interdisciplinary professionals during the entire gateway development project will allow public art to be more successfully integrated into the proposal from the onset. Proposing collaborative gateway design process guidelines, with background information on public art and the collaborative process, will guide the corridor communities in creating a destination for the RIC and the individual communities “achieving the shared vision of creating more vibrant, connected and green centers and corridors” (MARC CSP 2011, 1). Raytown, Missouri is used as an example demonstrating the materials which should be discussed during the initial design meeting in the collaborative gateway design process between the Consultant Team and the Design Advisory Council. Thinking of the RIC as an alternative transit amenity, establishing a collaborative design process and a general understanding of its components will allow for a true collaborative process to develop a destination for the community, the RIC, and KC Metro. Including public art in the collaborative design process will encourage more community involvement, potentially fostering a greater sense of ownership in the gateway, and personal investment in the community; engaging the residents to establish the foundation for a sustainable community capable of developing socially and economically over time.

Os Parques Tecnológicos têm se mostrado estratégias de desenvolvimento alinhadas a busca constante pela competitividade, ferramentas usadas por cidades, regiões e países em busca de sustentabilidade, auxiliando no fortalecimento tecnológico e na inserção na economia do conhecimento. Nesses centros de inovação, a produção, disseminação e uso do conhecimento são intensivos, e sua gestão torna-se imperiosa. Sendo assim, a Gestão do Conhecimento vem atender essa necessidade, e embora ela tenha alcançado um estágio consolidado como campo de pesquisa, a sua relação com os Parques Tecnológicos tem sido pouco explorada na literatura. Fundamentado na análise e reflexão dessas lacunas de pesquisa, este trabalho visa propor um conjunto de diretrizes para o desenvolvimento da Gestão do Conhecimento em Parques Tecnológicos. Para tal fim, foi desenvolvido e aplicado um instrumento de coleta de dados em cinco Parque Tecnológicos, sendo quatro no Brasil e um na Espanha. Os estudos de caso selecionados foram analisados, identificando iniciativas. Dessa forma obteve-se como diretrizes o desenvolvimento de um plano estratégico para a Gestão do Conhecimento, a organização de eventos para o incentivo à cultura; governança quádruplo hélice, canais de comunicação e layout planejado para suportar a estrutura, formação de uma equipe com responsabilidades explícitas, incentivo a projetos conjuntos, programas de capacitação, programas de softlanding e benchmarking, métricas, ferramentas e redes com parceiros estratégicos como fontes de conhecimento. Os resultados do trabalho contribuem para o desenvolvimento das pesquisas que relacionam as duas áreas de estudo, no âmbito empresarial a diretrizes propostas suportarão programas de implementação da Gestão do Conhecimento em Parques Tecnológicos. / The Technology Parks have proven development strategies aligned constant search for competitiveness, tools used by cities, regions and countries in search of sustainability, assisting in technological empowerment and inclusion in the knowledge economy. These innovation centers, production, dissemination and use of knowledge are intensive, and management becomes imperative. Thus, Knowledge Management meets this need, and although it has achieved a consolidated stage as a research field, its relationship with the Technological Parks was little explored in the literature. Based on the analysis and reflection of these research gaps, this paper aims to propose a set of guidelines for the development of Knowledge Management in Technology Parks. To this end, was developed and applied a data collection instrument in five Technological Park, four in Brazil and one in Spain. The selected case studies were analyzed, identifying initiatives. Thus it was obtained as guidelines to develop a strategic plan for knowledge management, the organization of events to encourage the culture; quad helix governance , communication channels and planned layout to support the structure , forming a team with explicit responsibilities, encouraging joint projects, training programs, Softlanding programs and benchmarking, metrics, tools and networking with strategic partners as sources of knowledge . The outcomes contribute to the development of research linking the two areas of study. In business under the proposed guidelines will support implementation of programs of Knowledge Management in Technology Parks.

Studies have reported that the most trusted health care relationship is that of the prenatal healthcare professionals (PHPs) and the prenatal patient. Yet many of the patient’s environmental health questions go unanswered for a variety of reasons. To better understand the situation, this research examines environmental health education practices of PHPs – obstetricians, prenatal nurses, family physicians, midwives and doulas - offered during the preconception and prenatal period. Specifically, this thesis discusses some of the PHP self-reported opportunities and barriers surrounding the provision of environmental health education (EHE). In person (n=17) and telephone (n=4) interviews were conducted with PHPs in the Ottawa Region. Additionally, a key informant within the Society of Obstetricians and Gynaecologists of Canada (SOGC) was asked specific questions about the association’s role in the development of standardized educational care guidelines. The results show that most PHPs have a limited knowledge of EHE and are reluctant to discuss it without access to more professional research. PHPs feel that there is little professional association support and that guidelines for adding EHE to their current prenatal care plans are non-existent. This study is one of the first studies that uniquely examined EHE in the prenatal period from perspective of prenatal healthcare professionals.

The development of Building Information Modelling (BIM) guidelines for campuses and universities has evolved on a case-by-case basis and there is no standard format in the development of these guides. There are however, common elements in these guidelines. This study reviews the applications of Building Information Modeling (BIM) from the perspective of owners of higher education campus facilities and proposes a structured approach to develop documented guidelines to assist the owner’s staff in the use of BIM, primarily with existing facilities. More specifically, this study proposes a set of guidelines to assist the Facilities Management department at Worcester Polytechnic Institute (WPI) in using BIM for their existing campus facilities. Since 2005, WPI has been using some components of BIM in the design and construction of new facilities and has extended BIM uses to support facilities and space management in some of the existing buildings. Some positive experiences and benefits have been derived from these applications, but to date no formal and systematic approach has been established in documenting and organizing processes for the different BIM uses on campus. The objective of this research project is to conduct an extensive review of documented approaches and guidelines for BIM uses developed by other universities and incorporate the different experiences with the use of BIM at WPI to create a set of formal guidelines exclusively for WPI for the efficient implementation of BIM in future design, construction, renovation, facility, and space management of a facility. The research collected information from the WPI Facilities Management department through surveys and interviews, to better understand the current issues associated with facility management and space planning. A case study analysis that involved the use of 3D Building Information Models of several buildings on the WPI campus was performed to validate the possible use of the BIM in the efficient delivery of information for new and renovation projects as well as for its ability to benefit in the space planning process. Existing documented guidelines developed by five other universities that have pioneered the development of their guides were also reviewed to determine common elements in their BIM-based practices and to incorporate these when applicable into the BIM guide for WPI in such a way that will effectively contribute to the BIM adoption and standardization of procedures reflecting the unique characteristics of this institution. This study identifies the benefits of utilizing BIM and standardization through the BIM guide primarily for existing construction and facilities management. The attempt to identify commonalities and standard pieces to develop a BIM guide for WPI will help improve overall operational efficiency and productivity of the organization. This provides a unique opportunity to be engaged in the process of standardization, using existing content as a reference to achieve harmonization of concepts, terms, definitions and the overall structure or framework that the documented guide is delivered within. The outcome is a WPI-BIM guide which will help assist facility owners in developing an overall BIM strategy that supports the organization’s core goals, develops the necessary contract conditions, and generates implementation plans to successfully execute BIM within the organization.