A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / Introduction: Patients who develop delirium while hospitalized are increasingly recognized as at risk for the development of long term cognitive impairment. We became interested in the contribution of delirium to the development of post-operative cognitive dysfunction (POCD) when we found that patients at Mayo Clinic in Arizona, compared to patients at the Mayo facilities in Rochester, MN, were 17 times more likely to receive the drug physostigmine (Antilirium®) for the treatment of delirium in the Post Anesthesia Care Unit (PACU). However, before we could examine the relationship between delirium and POCD we needed to validate a tool we could use to quickly assess the presence of delirium in patients emerging from anesthesia in the PACU. Hypothesis: The Confusion Assessment Method in the Intensive Care Unit (CAM-ICU) can be used in the PACU to identify patients with delirium. Methods: Patients 65 years of age or greater who were going to have a standardized general anesthetic for a surgical procedure were identified on the day of surgery and consent to participate in the study was obtained. The CAM-ICU was used preoperatively to determine study eligibility (patients who scored less than 7 [scale of 1-10], indicating delirium, on the test were not followed further) and postoperatively, one hour after the patient was admitted to the PACU, to assess for delirium. The CAM-ICU was administered after we asked the patient’s nurse whether or not he or she had determined that the patient was delirious. Results: 168 patients, mean age 75 ± 7 (SD) with the majority of participants having urologic or orthopedic procedures were assessed pre- and post-operatively with the CAM-ICU, and post-operatively by a nursing assessment for delirium. The CAM-ICU took little time to administer and was easy for patients to understand and use. The nurse at the bedside identified 5 of 168 patients as delirious (prevalence of 2.98%). The CAM-ICU was positive for delirium in 11 of 168 (6.55%). The CAM-ICU had a sensitivity of 60% (3/5) and a specificity of 95% (155/163). Conclusion: In this investigation, the CAM-ICU was easy to use and had a high specificity for identifying post-operative delirium.

This thesis considers how an assessment method for reinvestments in the distribution grid can be designed and implemented. The assessment method was created to give long-term estimations of the amount overhead lines that could be substituted with underground cables and how to prioritize between different areas. The regulation of power grid companies was reviewed to highlight important factors for profitable reinvestments. The assessment method was implemented for overhead lines in Ellevio´s distribution grid using the database program FME and validated against real reinvestment decisions in a case study area called Sinntorp. The resulting reinvestment proposals mainly consist of replacing older grid sections and sections where expensive maintenance is planned in the future. The script show similar results as real reinvestment decisions but small differences are noticed related to the script’s hard focus on older grid sections. The script has potential to be used on Ellevio´s entire overhead line network but this requires work to complete essential data. Further validation on new areas are also desired to see if results are reasonable and if the script can be developed to consider more reinvestment factors.

Följande uppsats syftade till att undersöka hur en standardiserad bedömningsmetod för rekrytering av familjehem (BRA-fam) implementerats utifrån ett urval av de kommuner som deltog i Socialstyrelsens pilotstudie (bilaga 1). Även sambandet mellan delaktighet och tillfredsställelse med implementering och förhållandet mellan forskning, profession och brukare undersöktes. Empirin har samlats in kvantitativt genom telefonintervjuer baserade på strukturerade enkäter. 46 kommuner som ingick i pilotstudien kontaktades, varav 30 familjehemsutredare besvarade frågorna (bilaga 2). Svaren har därefter redovisats och tolkats i form av tabeller och i text. Resultaten som analyserats och relaterats till teorier visar att utredning med BRA-fam-metoden upplevdes ha hög validitet och reliabilitet. Dock fanns svagheter i resultatet avseende delaktigheten i både metodval och implementering av metoden vilket kan bero på för få deltagare i undersökningen.Sammanfattningsvis framkom behov av att utvärdera rekryteringsmetoder inom familjehemsvården då implementering och användningen av metoden skiljer sig åt.Kommunerna har inte implementerat BRA-fam i sin helhet utifrån Socialstyrelsens rekommendationer. Användandet av metoden kan även skilja sig mellan såväl kommuner som privata aktörer. Förslag på förbättringsåtgärder och utvecklingsområden avseende implementering av metoder redovisas under rubrik Diskussioner och slutsatser.Ytterligare förslag ges för att närma sig en evidensbaserad, likvärdig och enhetlig rekryterings-metod inom familjehemsvården i Sverige. Detta för att om möjligt stödja, stärka och främja relationen mellan forskning, profession och brukare framöver och för att kunna möta de förändringar och utmaningar som ett samhälle utsätts och bär ansvar för. / The following essay purpose was to examine how a standardized assessment method for recruitment of foster homes (BRA-fam) implemented on a selection of the municipalities that participated in the National Board of Health and Welfare´s pilot study (appendix 1). The connection between participation and satisfaction with the implementation and the relationship between research, professionals and foster care system were also examined. Empirical data was gathered through quantity telephone interviews based on structured questionnaires. 46 municipalities who participated in the pilot study were contacted, of which 30 foster investigators answered the questions (appendix 2). The answers are then interpreted and reported in the form of tables and in the text. The results were analyzed and related to theories shows that investigation with BRA-fam method was perceived to have high validity and reliability. However, there were weaknesses concerning participation in both the methodology and implementation of this but might be consequences due to few participants.In summary, it emerged the need to evaluate the recruitment methods in practices within the foster home system and BRA-fam because the implementation and use of the method may differ. The municipalities have not implemented BRA-fam in its entirely based on the National Board of Health and Welfare recommendations. The use of the method differs between both municipalities and private operators. Suggestions for improvement and developmental areas regarding implementation of methods are presented in Discussion and conclusions.Further suggestions are given for approaching an evidence based, equitable and consistent recruitment method in foster care in Sweden. To support, strengthen and promote the relationship between research, professionals and social service users in the future and to meet the changes and challenges that a society is exposed to and responsible.

E-learning is one of the common education types in Turkey elsewhere in the world because it has been a necessity for higher and continuous education of people but what about its quality? There are a diverse number of factors which affect the quality of e-learning education but one of the most important factors is the student. Because students are at the center of education and all of the teaching-learning operations are performed for them, their impressions are very important to gain idea about the quality and improvement of education. In order to obtain information from students about e-learning process, questionnaires applied to 267 students and 203 of them were used for this study. The results showed that students were not able to get adequate support from teachers and success rates of the students were affected negatively by lack of immediate feedback. It was also inferred that learning objectives of the course were shared at the beginning but they were not emphasized throughout the term therefore students did not have enough knowledge about them. Moreover, according to the students almost all of the e-learning courses have similar assessment methods and they were not selected according to the predetermined learning objectives. Lastly, students mentioned that e-learning courses they had taken were not more beneficial than traditional ones but they will continue preferring them in the future. This shows that although there are still problems related with e-learning, students still prefer it because of its advantages for the students.

Wetlands are one of the most productive ecosystems in the world, housing diverse biota and serving important functions as nursery habitat and feeding grounds. However, nearly 70% of coastal wetlands, including 21% of the salt marshes in Texas, have been lost since 1950, due primarily to coastal development and declines in water quality. Restoration of wetlands is essential to reestablish lost functions, but there is no standard method to assess the ecological health of restored salt marshes in Texas. Numerous recent salt marsh restoration projects in Galveston Bay have made it an ideal model system to develop and implement an ecosystem health assessment, known as a rapid assessment method (RAM). In this study, I modified an established RAM, the Mid-Atlantic Tidal Fringe Assessment, to compare the ecological health of representative reference salt marshes to restored marshes around Galveston Bay. I measured 14 biotic and abiotic characteristics at 12 restored and 6 reference sites around Galveston Bay, and then grouped those measurements into four functional groups: landscape/site characteristics, hydrology, wildlife habitat, and soil characteristics. I then developed a scoring system (minimum 0, maximum 100) to summarize the overall health of each site. Most of the restored salt marshes in this study scored lower than reference marshes. The average reference site score was 81.8 and the average restored site score was 69.7. Functional group values for landscape/site characteristics, soil, and wildlife habitat were significantly lower in restored than in reference sites. In particular, restored sites had more hydrological modifications, more fill material, and fewer macrobenthos than reference wetlands. The Galv-RAM effectively and efficiently identified restoration successes and weaknesses. With this information, management agencies can address restoration shortcomings by adapting management goals. The Galv-RAM will streamline monitoring protocols and facilitate long-term examination of restored wetland health. As a result, management decisions can be modified based on the scores received in different categories or variables to improve and or meet the goals of the project.

The application of environmental assessment methods for buildings has increased significantly over the last few years. Approximately five years ago Riksbyggen decided to apply Miljöbyggnad Silver to the new construction of all their apartment buildings. Internally within the organisation, however, criticism that the system causes large design and construction costs has been lifted. The aim of this study was to investigate the magnitude of the design and construction expenses related to Miljöbyggnad and to find what improvements could be implemented to reduce costs and enforce the efficiency of the process. The second part of the study included a feasibility study regarding implementing Life Cycle Assessment, LCA, in the construction process. The purpose of including LCA would be to construct buildings with a reduced climate impact. There are convincing indications that LCA will become an increasingly important tool in the construction industry in the future.   The project leaders working with Miljöbyggnad at Riksbyggen completed a questionnaire considering the expenses Miljöbyggnad Silver causes beyond Boverket’s Building Regulations,as well as determining the attitude regarding a possible implementation of Life Cycle Assessment. The results were subsequently discussed more qualitatively during follow-up meetings and additionally with other professionals in the industry.   The project leaders' perception of the prevailing expenses associated with Miljöbyggnad Silver beyond the Boverket’s Building Regulations varied greatly, which was consistent with previous international studies. The total cost of the use of Miljöbyggnad was stated in the large range of 400.000 to 3.800.000 SEK, but when the most divergent estimates were excluded, a more limited range of 400.000 to 650.000 SEK was given. The project leaders estimated that the certification increased the project's total cost to an extent of 0.13 to 8%, but when excluding the most divergent estimates the interval was reduced to 0.13 to 2%. The project managers’ merged results emphasized that the most cost-bearing indicators were, with the most costly first, solar heat load, daylight, thermal climate summer, absence of hazardous substances and documentation of materials.   The project leaders’ knowledge regarding LCA was limited. The main reason for their reluctance to implementation seemed to be the additional work and expense it could entail. In principle, all project leaders were of the opinion that LCA should be integrated in an early project stage prior to the procurement of a contractor. / Tillämpningen av miljöcertifieringar för byggnader har de senaste åren ökat kraftigt i omfattning. Riksbyggen tillämpar sedan några år tillbaka Miljöbyggnad ambitionsnivå Silver för all nyproduktion av flerbostadshus. Internt inom organisationen har dock kritik framhållits avseende att systemet föranleder stora ökningar av investeringskostnaderna. Eftersom få studier beträffande eventuella merkostnader av miljöcertifieringssystem genomförts har det för Riksbyggen varit svårt att svara på kritiken. Syftet med studien var följaktligen att utreda investeringskostnadernas omfattning samt vilka förbättringsåtgärder som skulle kunna vidtas för att reducera kostnaderna och parallellt stärka certifieringens ändamålsenlighet. Den andra delen av studien inbegriper en förstudie avseende en eventuell implementation av livscykelanalys, LCA, för byggprocessen. Mycket tyder på att LCA kommer att användas allt mer inom byggindustrin framöver för att uppföra byggnader med en reducerad klimatpåverkan.   Riksbyggens projektledare besvarade en enkätundersökning avseende de kostnader Miljöbyggnad Silver tillfogar utöver Boverkets byggregler, BBR, samt en undersökning avseende deras inställning till en eventuell implementation av livscykelanalyser. Enkätundersökningen kompletterades med uppföljningsmöten under vilka enkätresultaten diskuterades mer kvalitativt samt genom möten med andra professionellt yrkesverksamma.   Projektledarnas perception av kostnaderna förenade med Miljöbyggnad Silver utöver BBR varierade kraftigt, vilket dock överensstämde med tidigare internationellt genomförda studier. Totalkostnaderna för certifieringen befann sig i ett intervall av 400–3800 tusen kronor, tkr, men då de mest avvikande uppskattningarna exkluderades begränsades kostnadsintervallet till 400–650 tkr. Projektledarna uppskattade att certifieringen innebar ett kostnadspåslag på projektets totalkostnad av 0,13 till 8 %, men då extremerna exkluderades begränsades intervallet till 0,13–2 %. Projektledarnas sammanslagna resultat indikerade att de mest kostnadsdrivande indikatorerna var, med den mest kostnadsdrivande först; solvärmelast, dagsljusfaktor, termiskt klimat sommar, utfasning av farliga ämnen samt dokumentation av byggvaror. Projektledarnas kunskapsbild avseende LCA var relativt begränsad och de främsta betänkligheterna beträffande en implementering tycks vara den eventuella arbetsbelastning det skulle kunna medföra samt de kostnader det skulle driva. Den viktigaste frågan beträffande en LCA-implementering är hur Riksbyggen på bästa sätt integrerar livscykelperspektivet i verksamheten. Majoriteten av projektledarna var av åsikten att LCA vid en implementering bör integreras i ett tidigt projektstadium framför vid upphandling av entreprenör.

A Quality Improvement project to initiate the Confusion Assessment Method (CAM) delirium screening tool at a Skilled Nursing Facility and Rehabilitation Center in East Tennessee -- by S. Joseph Jadav, Doctor of Nursing Practice Candidate at East Tennessee State University. Purpose/Aims: The aim of this project is to implement a delirium screening protocol in a skilled nursing and rehabilitation facility which will aid in early detection of signs and symptoms of delirium in older adults. This early detection followed by an early intervention can help reduce costs and decrease mortality rates with better outcomes. Processes: A CAM screening is conducted on each patient (male & female) for delirium for a period of four weeks. Data collection will comprise of the number of patients assessed and the total number of positive and negative delirium cases. It was determined that the proposed activity is not research involving human subjects according to United States Department of Health and Human Services (DHHS) regulations by the university’s Institutional Review Board (IRB). Results: The project is currently in the data collection phase. Limitations: Refusal to participate either by the patient or family in the screening. Conclusions: While nearly 80% of delirium cases in an acute care setting go undetected or undiagnosed, this project to implement a delirium screening protocol in a skilled nursing facility is even more imperative in early detection and early intervention.

The aim: was to describe and compare a group of experts and critical care nurses' agreement in detecting delirium in intubated, ventilator treated patients with sedation / analgesia, before and after an in house training intervention with the instrument Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Method: A quasi-experimental study, one group pretest - posttest design. A convenience sample of 17 critical care nurses in a general intensive care unit included. To detect delirium the instrument CAM-ICU was used, 21 paired tests before and 22 after an educational intervention. Main Results: The results showed that after an in house training intervention sensitivity and kappa coefficient improved of the characteristic 1 "acute onset and fluctuating course," an improvement that was significant. In other features, and overall values were signs of numerical improvement and deterioration in sensitivity, specificity and kappa coefficient but no significant change. Conclusion: Implementing a new instrument for detecting delirium in clinical practice requires education and follow-up. A small sample of critical care nurses with varying ability to use the new instrument and the fact that patients' status may change rapidly making it difficult to draw any conclusions from this study. It is clear, however, that education and follow-up is needed when new care routines are introduced, and that further studies are needed to clarify whether the CAM-ICU is a valit and reliable instrument to use in clinical practice. / Syftet var att beskriva och jämföra en expertgrupp och intensivvårdssjuksköterskors överensstämmelse i att detektera delirium hos intuberade, respiratorbehandlade patienter med sedering/analgesi, före och efter en utbildningsintervention med instrumentet Confusion assessment method for the intensive care unit (CAM-ICU). Metod: En kvasiexperimentell studie, en grupps pretest – posttest design. Ett bekvämlighetsurval på en allmän intensivvårdsavdelning där inkluderades 17 intensivvårdssjuksköterskor. För att detektera delirium användes instrumentet CAM-ICU, 21 parmätningarna före och 22 efter en utbildningsintervention. Huvudresultat: Resultatet visade att efter utbildningsinterventionen förbättrades sensitiviteten och kappa koefficienten i kännetecken 1 ”akut insättande eller fluktuerande förlopp”, en förbättring som var signifikant. I övriga kännetecken och totalvärden fanns tecken på numerär förbättring och försämring i sensitivitet, specificitet och kappakoefficient men ingen signifikant förändring. Slutsats: Att implementera ett nytt instrument för att detektera delirium i klinisk verksamhet kräver utbildning och uppföljning. Ett litet sample av intensivvårdssjuksköterskor med varierad förmåga att använda det nya instrumentet samt det faktum att patienters status hastigt kan förändras gör det svårt att dra några slutsatser av denna studie. Klart är dock att utbildning och uppföljning behövs när nya vårdrutiner införs, och att ytterligare studier behövs för att klargöra om CAM-ICU är ett valit och reliabelt instrument att använda i klinisk verksamhet.

La pollution des eaux de surface par les pesticides est un problème sérieux. Cette pollution étant en grande partie liée à l’activité agricole, la mise en place de pratiques permettant de limiter les transferts de pesticides vers les eaux de surface représente une solution intéressante. Afin d’apprécier l’efficacité de tels projets il est important de développer des méthodes spécifiques d’évaluation agri-environnementale. Si les méthodes d’évaluation parcellaires sont opérationnelles, celles à l’échelle du bassin versant ne sont pas encore bien adaptées aux besoins des acteurs de terrain. Ce travail a pour objectif de développer un indicateur de risque d’exposition des eaux de surface aux pertes de pesticides par ruissellement à l’échelle du bassin versant. Pour ce faire, nous avons développé deux indicateurs : un indicateur parcellaire évaluant l’impact des pratiques agricoles sur les pertes de pesticides par ruissellement en sortie de parcelle et un indicateur de connectivité estimant la contribution de chaque parcelle au ruissellement global du bassin versant. Le couplage de ces deux indicateurs permet d’obtenir un outil d’évaluation du risque des pratiques phytosanitaires spécifique d’un bassin versant et de comparer des scenarii. Les méthodes de développement des deux indicateurs se distinguent des méthodes classiques par leur fondement sur un couplage indicateur / modèle. L’hypothèse méthodologique principale sur laquelle repose ce travail est qu’à partir des processus décrits par les modèles, il est possible d’explorer une gamme de situations très large et de créer une base de connaissances qui permet de développer nos indicateurs / Surface water pollution by pesticides is a great environmental concern. In order to limit pesticides transfers from agricultural field to surface water, mitigation strategies are implemented. Their effectiveness has then to be assessed by specific tools. Most of pesticide runoff risk assessment tools are simple indicators or simulation models. Both can be performing for field application but most of the available methods are not yet adapted to help catchment managers in their decision process. Simple indicators lack taking into account inherent variability of watersheds structures and mechanistic models demands too many data to be used as routine tools. The aim of this study is then to develop a catchment scale pesticide runoff risk assessment tool to help catchment managers to identify risky situations. We developed two indicators: one to assess agricultural impact on pesticide runoff risk at a field scale and the other field spatial position impact on runoff route from the field to the hydrological network. Aggregating those two indicators lead us to assess catchment fields pesticide runoff risk and allows comparing agronomical or climatic scenarios. We based both indicators on modelling assuming that processes described by model make possible to explore wide factors variation ranges and to build databases on which indicators are developed

Intrinsically safe (IS) active power supplies subjected to certain transient load conditions can deliver power to a circuit at significantly higher levels than indicated on their nameplate ratings. During a transient load such as an intermittent short-circuit, energy is transferred from the power supply to the short-circuit and an electrical arc may form when the short-circuit is applied or removed. This poses a spark ignition risk as energy is transferred from the arc to the surrounding atmosphere. Currently various International and Australian Standards define the performance requirements for IS electrical apparatus. A duly accredited laboratory is required to establish the intrinsic safety compliance of an apparatus with the Standards. It involves an assessment of the apparatus and may include testing. The assessment of the apparatus determines adequate segregation, separation, construction, and selection of components. The tests performed on the apparatus include a temperature rise test and in some cases, the sparking potential of the circuit is tested using the spark test apparatus (STA). Testing the sparking potential of active power supplies to establish compliance adds significantly to the time and costs involved in establishing compliance. A new alternative assessment method is proposed in this report to augment or replace the testing phase of the compliance certification process for active power supplies. The proposed alternative assessment method (PAAM) is derived from a determination of the steady-state and transient output characteristics of the active power supply under consideration. Parameters such as peak output current, time constant of peak current decay, and the output voltages at these times are measured from the circuit's output characteristics. These measurements can subsequently be used to derive the topology and component values of an equivalent circuit. The resulting equivalent circuit is then considered like a linear power supply and the sparking potential can be determined using existing assessment methods. This thesis investigates in detail the equivalent circuit of a number of direct current (DC) active power supplies whose transient output characteristics exhibit predominantly capacitive behaviour. The results of the PAAM using the equivalent circuit are then compared with results achieved using the current testing procedure with a STA. A small sample of active power supplies is used to generate data from which a relationship between the current testing procedure and the PAAM can be established. The PAAM developed in this research project can be used as a pre-compliance check by designers, manufacturers, or IS testing stations. A failure of this test would indicate that the active power supply's sparking energy is not low enough to be regarded as intrinsically safe. The PAAM requires fewer resources to establish a result than the STA. The benefits of a simplified spark ignition test would flow on from designers and manufacturers to end users.