Thesis (M. S.)--Architecture, Georgia Institute of Technology, 2007. / Augenbroe, Godfried, Committee Chair ; Cowan, David, Committee Member ; Zimring, Craig, Committee Member.

Background: CATs is a hospital admission triage tool for influenza and pneumonia, and comprises of 7 criteria (6 objective and 1 subjective); any one of which is expected to trigger hospital admission in adults and children. As the CATs was only recently developed, its performance has only been assessed in the United Kingdom using data from the 2009 A (H1N1) flu pandemic. An external validation study is thus required to assess the generalisability of the CATs in a new patient population before it is recommended for adoption in practice. Aim: The primary aim of this thesis was to prospectively evaluate the predictive performance of the Community Assessment Tools across a range of acute lower respiratory tract infections in a new geographical setting. Five studies were included in this thesis, each addressing a specific objective in order to achieve the primary aim of this research: • The first study examined the predictive performance of individual CATs criteria with regard to the need for hospital based care and mortality, • The second study examined the performance of CATs as unweighted and weighted scoring indexes for assessing these outcomes in adults and children with ALRTI, • The third study compared the performance of the unweighted CATs scoring index and the well-established pneumonia severity score –CRB65 in two separate sensitivity analyses involving cases of suspected ALRTI and pneumonia in adults. • The fourth study sought to investigate the value of clinical intuition in medical decision-making by comparing the performance of the CATs as an unweighted scoring index with or without the inclusion of its subjective criterion (causing other clinical concern). • The fifth study was a qualitative exploration of critical care practices in Nigerian hospitals, conducted to provide contextual interpretation of findings related to the performance of the CATs in predicting the need for critical care and mechanical ventilation. Methods: Data specific to the CATs and CRB65 were recorded at the initial consultation of patients with symptoms suggestive of an acute lower respiratory tract infection. The performance of the tools with regard to predicting the need for hospital admission , acute care interventions (supplemental oxygen, IV antibiotics and IV fluids), or any deaths on admission were assessed using specificity, sensitivity, negative and positive predictive values, Area under Receiver Operating Characteristic Curves (AUROC) with 95% confidence intervals and Hosmer-Lemeshow goodness-of-fit test. The qualitative study was conducted within a pragmatic paradigm and a semi-structured guide was used to for individual interviews with key hospital staff. Thematic analysis was used for analysing interview data. Results: Data were obtained for 1016 (809 children < 16years) consecutive patients from four hospitals in Lagos Nigeria. In the univariate analysis each CATs criterion significantly predicted an outcome which indicated the need for hospital care or mortality, also none of these criteria were redundant in the multivariable analysis. Criterion C representing low oxygen saturation levels of 92% or less and Criterion G –clinicians’ intuition or gut feelings ,were the best predictors of the need for hospital based care and risk of death in both children and adults. The predictive accuracy of the individual criteria was generally low in terms of AUROC values, but this improved when they were combined to create scoring indexes. An unweighted CATs threshold score of three points or more was appropriate for identifying both adults and children who would potentially benefit from hospital based care and therapeutic interventions. In the comparison between CRB65 and the unweighted CATs score, the latter was seen to have better discrimination and calibration qualities for predicting all outcomes in adults with ALRTI, and although both the unweighted CATs and CRB65 scores demonstrated good predictive ability for the outcome ‘in-hospital mortality’ in adults with pneumonia, the unweighted CATs score outperformed the CRB65 in terms of AUROC values, however, the difference was marginal and statistically insignificant. This thesis provided evidence to support considering clinical intuition or gut feelings in the assessment of patients with ALRTI, as the predictive performance of the unweighted CATs score was significantly better with the inclusion of subjective criterion G (causing other clinical concern) than when this criterion was omitted. Due to insufficient data it was not possible to assess the performance of the CATs in regard to the outcome ‘need for critical care’. Findings from the qualitative study revealed that ALRTI was not a common indication for ICU admission in these hospitals, also that clinical predictions tools were not generally used in this regard, rather decisions regarding ICU admissions were determined by the ability to pay and bed availability. Conclusion: the CATs criteria showed geographical generalisability despite differences in case-mix and geographical variations. When combined to create an unweighted scoring system, CATs showed good potential for guiding decisions to admit adults and children with ALRTI to hospital for further care. Although CATs was developed for use during an influenza pandemic, the unweighted CATs score could be a useful tool for guiding admission decisions in adults with interpandemic pneumonia, as it performed reasonably well when compared with a widely validated and established pneumonia severity score.

Thesis (MArch(Prof)) -- University of Pretoria, 2008. / Abstract in English. Includes bibliographical references.

INTRODUCTION Exclusive breastfeeding (EBF) for the first six months of an infant‟s life is recognized by the World Health Organisation (WHO) and the United Nations Children‟s Fund (UNICEF) as the most effective and essential strategy for optimal growth and prevention of infant mortality. One of the factors that influences a mothers choice to exclusively breastfeed her child, is the marketing of breast milk substitutes. The International Code of Marketing of Breast-milk Substitutes (ICMBS) was developed to promote, protect and support EBF. Although South Africa (SA) has voluntarily adopted the ICMBS in 1981 to help protect and promote EBF, the exclusive breastfeeding rates in SA remain very low (<8%). In a renewed attempt to protect and promote exclusive breastfeeding in SA, the code has been legislated in December 2012 to ensure compliance. AIM To assess the extent of ICMBS violations in health facilities in four Provinces in SA. DESIGN This was cross-sectional study. A purposive stratified cluster sample of eight to twelve health facilities was drawn in four Provinces (Gauteng, North-West, Free-State and Eastern Cape) in SA. Fixed structured interviews were conducted by trained fieldworkers with three health workers from each of the 40 health facilities to determine the extent of ICMBS violations as well as awareness of the ICMBS. The receipt of free gifts, free/low cost supplies/samples of formula milk, bottles or teats, and free materials or equipment from companies who sell breast-milk substitutes (BMS), infants foods/drinks and bottles or teats (violation of articles 6.2, 6.3, 6.6, 6.8, 7.3 and 7.4 of the ICMBS) were determined. RESULTS A total number of four violations were reported by four health workers from three of the 40 health facilities (7.5%). ICMBS violations were reported only in Gauteng Province with no violations in North West, Free State or Eastern Cape Province. All four violations involved the receipt of free gifts for personal use (including a pen, booklet, calendars and booklet/poster) from a BMS company (Nestlé), violating article 7.3 of the ICMBS. Health workers from four health facilities also reported the receipt of information materials and/or equipment for use in the facility, including leaflets, maternal and infant feeding product booklets and water bags from Nestlé. However, since the brand name of a product within the scope of the ICMBS was not visible on any of the materials or equipment, none of these gifts constituted a violation. In terms of ICMBS awareness, 46 health workers (38%), including the four health workers who received gifts, from 19 health facilities situated mainly in Eastern Cape and Gauteng Province were familiar with the ICMBS. CONCLUSIONS Violations were reported in 7.5% of health facilities, including the health facilities where health workers were aware of the code. Implementation and training of the ICBMS in health facilities is there for warranted. / MSc (Nutrition), North-West University, Potchefstroom Campus, 2015

INTRODUCTION Exclusive breastfeeding (EBF) for the first six months of an infant‟s life is recognized by the World Health Organisation (WHO) and the United Nations Children‟s Fund (UNICEF) as the most effective and essential strategy for optimal growth and prevention of infant mortality. One of the factors that influences a mothers choice to exclusively breastfeed her child, is the marketing of breast milk substitutes. The International Code of Marketing of Breast-milk Substitutes (ICMBS) was developed to promote, protect and support EBF. Although South Africa (SA) has voluntarily adopted the ICMBS in 1981 to help protect and promote EBF, the exclusive breastfeeding rates in SA remain very low (<8%). In a renewed attempt to protect and promote exclusive breastfeeding in SA, the code has been legislated in December 2012 to ensure compliance. AIM To assess the extent of ICMBS violations in health facilities in four Provinces in SA. DESIGN This was cross-sectional study. A purposive stratified cluster sample of eight to twelve health facilities was drawn in four Provinces (Gauteng, North-West, Free-State and Eastern Cape) in SA. Fixed structured interviews were conducted by trained fieldworkers with three health workers from each of the 40 health facilities to determine the extent of ICMBS violations as well as awareness of the ICMBS. The receipt of free gifts, free/low cost supplies/samples of formula milk, bottles or teats, and free materials or equipment from companies who sell breast-milk substitutes (BMS), infants foods/drinks and bottles or teats (violation of articles 6.2, 6.3, 6.6, 6.8, 7.3 and 7.4 of the ICMBS) were determined. RESULTS A total number of four violations were reported by four health workers from three of the 40 health facilities (7.5%). ICMBS violations were reported only in Gauteng Province with no violations in North West, Free State or Eastern Cape Province. All four violations involved the receipt of free gifts for personal use (including a pen, booklet, calendars and booklet/poster) from a BMS company (Nestlé), violating article 7.3 of the ICMBS. Health workers from four health facilities also reported the receipt of information materials and/or equipment for use in the facility, including leaflets, maternal and infant feeding product booklets and water bags from Nestlé. However, since the brand name of a product within the scope of the ICMBS was not visible on any of the materials or equipment, none of these gifts constituted a violation. In terms of ICMBS awareness, 46 health workers (38%), including the four health workers who received gifts, from 19 health facilities situated mainly in Eastern Cape and Gauteng Province were familiar with the ICMBS. CONCLUSIONS Violations were reported in 7.5% of health facilities, including the health facilities where health workers were aware of the code. Implementation and training of the ICBMS in health facilities is there for warranted. / MSc (Nutrition), North-West University, Potchefstroom Campus, 2015

The incidence of Heath Care Associated Infection is a major patient safety concern in the United Kingdom and reducing the morbidity and mortality associated with this has become a National Health Service priority. It is generally accepted that this objective will require a multi-factorial approach where infection prevention and control is seen as everybody’s business. However, some strategies receive greater exposure than others and hand hygiene is widely touted as a common sense solution to a complex problem. This discourse based study combined the techniques of Corpus Linguistics with Critical Discourse Analysis to explore the Textual, Discursive and Sociocultural features of hand hygiene discourse. This took place across three language domains, the Academy, the Newspaper Media and Organisational Policy Makers. These three cultural elites take a consistent account of the problem and the solution. Broadly hand hygiene is portrayed as effective, compliance is basic, performance is poor and Health Care Workers should be held to account through zero tolerance policies and if necessary disciplinary action. However, not only does this background the messy, contextual factors of implementing a hand hygiene policy it imposes a one size fits all approach and measurement programme on compliance that hides the true nature of performance and this ultimately impacts on patient care. This study calls for junior clinicians for whom policy has the greatest impact to become more engaged in the policy making process. In a spirit of openness trusts should adopt linguistic devices that recognise the dynamic nature of practice and a more educational, sophisticated approach to audit.

In the UK the National Health Service (NHS) faces the challenge of securing £20 billion in savings by 2014. Improving healthcare productivity is identified by the state as essential to this endeavour, and critical to the long-term future of the NHS. However, healthcare productivity remains a contentious issue, with some criticizing the level of professional engagement. This thesis explores how contemporary UK policy discourse constructs rights and responsibilities of healthcare professionals (HCPs) in terms of productive healthcare, how this is made manifest in practice, and the implications for professional autonomy/identity. Using analytical lenses from the sociology of professions, identity formation and the Foucauldian concept of governmentality, it is proposed that policy discourse calls for a new flavour of professionalism, one that recognises improving healthcare productivity as an individualised professional duty, not just for an elite cadre but for all healthcare professionals. Adopting an ethnographic approach (participant observation, semi-structured interviews, focus group and document analysis), data is presented from a large UK Emergency Department (ED), exploring the extent to which this notion of self-governance is evident. The study elucidates the ways in which: professional notions of productivity are constructed; productive work is enacted within the confines of the organisational setting; and tensions between modes of governance are negotiated. The findings of this study suggest that HCPs perform identity work via their construction of a multidimensional notion of healthcare productivity that incorporates both occupational and organisational values. Whilst responsibility for productivity is accepted as a ‘new’ professional duty, certain ethical tensions are seen to arise once the lived reality of ‘productive’ work is explored within the organisational field. The complex interplay of identity work and identity regulation, influenced by the co-existence of two differing modes of governance, results in a professional identity which cannot be represented by a static occupational/organisational hybrid, but rather one that is characterised by continual change and reconstitution. Understanding healthcare productivity from this perspective has implications for professional education, patient care, service improvement design and the academic field of the sociology of professions.

Studies were conducted in Nottingham, UK to assess quality of discharge summary communication sent from secondary to primary care using updated processing methods. Objectives (1) Assess available evidence on effectiveness of interventions aiming to improve discharge information communication specifically introducing computerised discharge summaries (2) Assess differences in discharge summary quality using new processing methods (3) Obtain perspectives of secondary care on discharge communication issues, identifying points of weakness and primary care views on discharge information communicated from hospital. Methods (1) Systematic review of literature on effectiveness of interventions aiming to improve discharge summary information communication (2) Before and after studies of two different discharge summary types in three departments within Nottingham University Hospitals NHS Trust (3) Qualitative interviews with key stakeholders (N=27) and observations in 3 sites. Results The systematic review returned 21 interventions with emphasis on the introduction of computerised systems to improve quality (timeliness and completeness of discharge summaries). Nine studies significantly improved the completeness of the discharge summary. Ten studies significantly increased the timeliness of the generation of the document and the transfer of information. The three before and after studies produced varying results; the HCOP findings suggested improvements post-intervention in completeness of summaries; this was not statistically significant. In Nephrology, computerisation significantly speeded up the timeliness of discharge summaries but there was no significant difference in completeness between the two types. In Paediatrics, computerisation increased the number of summaries not completed, and the handwritten summary was significantly faster. Computerised discharge summaries contained more information- this was statistically significant. The qualitative study identified issues with understanding the concept of discharge, the purpose and importance of the discharge summary, and organisational issues around the ability to balance the demands for completeness and timeliness, a lack of leadership and user-centred design of the electronic discharge system. Conclusions The literature reviewed found examples of the potential computerisation has on discharge documentation quality. The research studies conducted showed that the introduction of computerisation into the discharge documentation process produced mixed results in quality (completeness and timeliness) of discharge summaries communicated from secondary to primary care. Slight improvements were found in the before and after studies and staff feedback was positive. The success of such interventions depends largely on increased clinical leadership and user-centred design. An established link to patient safety is needed to increase awareness of the importance of discharge summary communication and justify major system change.

Introduction Studies have shown that a proportion of patients admitted to hospital do not require the intensity of services they provide. Also, the admission of patients can be for an inappropriate duration. Methods Three studies were conducted. The first study was a record review to determine the appropriateness of patient admissions and inpatient stays. The second examined the wider causes of inappropriate admissions/inpatient stays as perceived by clinicians, and identified interventions to reduce such admissions/stays. Data were collected using focus groups. The final study explored barriers to service use from the perspectives of clinicians and patients. Data were collected from clinicians via an online questionnaire and from both clinicians and patients using semi structured in-depth interviews. Results Of 119 patients, 32 were admitted inappropriately and 83 were admitted for an inappropriate duration. Risk factors for an inappropriate admission included living in the community compared to a nursing/residential home, and for an inappropriate length of stay included the number of presenting complaints, number of long term neurological conditions and whether the participant lived alone in their own home or with others. In the second study, the limited knowledge and a lack of health and social care resources in the community, were perceived as causes of inappropriate admission/lengths of stay. Interventions to prevent inappropriate admissions/lengths of stay included: sub-acute care facilities and patient held summaries of specialist consultations, among others. The final study found that the main barriers to use of services were out of hour's access and unfamiliarity of clinicians with local service provision. Conclusions The causes of inappropriate admissions/lengths of stay related, in main, to communication problems and accessibility of services. Interventions to improve transference of information and knowledge regarding long term condition management and service provision may be warranted.

This study involved the development and implementation of a model for providing structured on-the-job training (SOJT) in a healthcare foodservice operation. The model was developed to provide a structured method for conducting SOJT Events, the process when an incumbent employee trainer teaches another employee to perform his/her job. The model was composed of four components, each serving to support the Event. An SOJT Event Process established a series of steps to follow when conducting SOJT. A Training Manual and Training Checksheet were Support Documents used to assure the consistency of each Event and to document standard procedures. Trainers were prepared to conduct Events during the Trainer Preparation Workshop. Finally, the last component was the SOJT Event Performance Support System, a set of guidelines devised to create the support network necessary for Events to be carried out in the work setting. The model was implemented as each Trainer was scheduled to conduct two SOJT Events over a three month period. It was tested by measuring Trainee knowledge, performance and assessment of the SOJT Events. Other employees, who had been trained with unstructured training in the past served as control groups. Subjective observations of the applicability and acceptability of the model among employees were also noted. The model was successful in producing knowledge gains among Trainees. Trainees who were recipients of SOJT assigned higher assessment scores to SOJT than control group employees assigned to unstructured on-the job training. There was no difference in performance among employees trained using structured or unstructured on-the-job training. Employees that were directly involved in the SOJT Events were positive about supporting the model. Modifications for the model and the components are suggested. It was concluded that the model components that were developed and the use of a consultant with experience in training and instructional design are necessary for implementation of structured on-the-job training in foodservice operations. / Graduation date: 1992