The quality of care for Swedish patients with acute myocardial infarction (AMI) is continuously increasing. Nevertheless, a great potential for improvement still exists. The aim of the present study was to design and implement a systematic quality improvement (QI) collaborative in the area of AMI care, and to validate its usefulness primarily by analyzing its effect on hospital adherence to national guidelines. Also, the impact on patient morbidity and mortality was to be evaluated. The intervention was based on proven QI methodologies, as well as interactive use of a web-based quality registry with enhanced, powerful feedback functions. 19 hospitals in the intervention group were matched to 19 similar control hospitals. In comparison with the control group, the intervention group showed significantly higher post-interventional improvements in 4 out of 5 analyzed quality indicators (significance shown for ACE-inhibitors, Clopidogrel, Heparin/LMWH, Coronary angiography, no significance for Lipid-lowering therapy). From baseline to the post-intervention measurement, the intervention hospitals showed significantly lower all-cause mortality and cardiovascular re-admission rates (events per 100 patient-years; -2,82, 95% CI -5,26 to -0,39; -9,31, 95% CI -15,48 to -3,14, respectively). No significant improvements were seen in the control group. The improved guideline adherence rates in the intervention hospitals were sustained for all indicators but one (ACE-inhibitors), this during a follow-up measurement three months after study support withdrawal. No effects were seen on any indicators other than those primarily targeted. In conclusion, by combining a systematic QI collaborative with the utilization of a national quality registry, significant improvements in quality of care for patients with AMI can be achieved.

Background: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, with a higher incidence in older adults (Iwasaki, Nishida, Kato,& Nattel, 2011). There are limited data regarding AF care for adults in rural communities with AF. Purpose: The purpose of this study was to determine whether patients in a rural community hospital received AF care based on American Heart Association (AHA) Get with the Guidelines-Atrial Fibrillation (GWTG-AF) standardized guidelines and whether use of these guidelines was associated with improved thirty day outcomes. Methods: A retrospective medical records review was used. Medical records of patients with AF as primary or secondary diagnoses in inpatient or emergency department admissions were reviewed to determine whether AF guideline care was provided during the hospital stay. AHA GWTG-AF was used to evaluate guideline based care (January, et al., 2014). Results: The results from this study showed that while quality care is provided to rural patients with AF, standardized guideline care is not consistently provided. Preventative care, such as use of angiotensin converting enzyme inhibitors (ACE-I) or angiotensin receptor blockers (ARB) was only provided for 50% of patients who required it. Evaluation of thromboembolism risk was not consistently provided for AF patients. Use of the congestive heart failure, hypertension, age, diabetes, stroke, vascular disease, age, sex category (CHADS₂/CHA₂DS₂VASc) score was not used in the emergency department or observation units (ED/OBS) and limited use of CHADS₂/CHA₂DS₂VASc score was shown in the inpatient environment, with only 19.5% of patients receiving assessment of thromboembolism risk. Bleeding risk was not documented by clinicians, such as the hypertension, abnormal renal/liver function, stroke bleeding predisposition, labile INR, elderly, drugs/alcohol (HAS-BLED) score. Thromboembolism medications were administered to 156 (78%) of the patients without documentation of these risk factors. Rate control strategies were used more frequently than rhythm control strategies (76% compared to 15%). There were three readmissions for minor bleeding during the pre-selected readmission window, and did not exhibit enough data to generalize whether immediate 30 day outcomes are affected by adherence to guideline care. Conclusions: While some of the GWTG-AF guidelines are followed for AF patients in this rural environment, there are significant areas where adherence to the guidelines is limited. Use of preventative care measures, thromboembolism risk, bleeding risk, and appropriate anticoagulation administration for patients at risk were areas that did not have adequate guideline adherence. Future research is needed to evaluate what barriers may exist to using guideline based care. Such research can also serve as the basis for education programs for clinicians to increase adherence to guideline care. In addition, future research may include a longer readmission period to evaluate for improved outcomes.

Master of Science / Civil Engineering / Sunanda Dissanayake / The percentage of gravel roads in rural areas in Kansas is higher than most states. A wide variation of traffic volumes across different regions and variations of local conditions and scenarios present a great challenge for local agencies to determine suitable roadway surface types for local rural roads, especially considering constraints on transportation budgets. The primary objective of this research was developing specific guidelines to identify the most suitable roadway surface for a particular roadway section with given conditions. Surveys were carried out to determine the importance of factors affecting the selection of a roadway surface type, where were later used for guideline development. General guidelines were developed using the multi-criteria assessment method in order to fulfill the main objective. The main important factors in decision-making were identified as agency cost, safety, Vehicle Operating Cost (VOC), traffic volume, purpose of road usage, and public preference. Multi-criteria assessment method involves calculating the weights for the factors important in decision-making, the respective scaled values for each factor for paved surface and gravel surface, and eventually calculating the final score for paved and gravel surface type. Equations were formulated to carry out life cycle cost (LCC) analysis along with the present worth evaluation. The formulas provided flexibility to calculate agency cost by considering local variation. VOC was calculated for paved and gravel roads considering variations in speed of different classes of vehicles, gradient and horizontal curve of the road, and the conversion factor for cost on paved surface versus gravel surface. Safety analysis was carried out for local rural roads in Kansas for five years, from 2010 to 2014, using the Kansas Department of Transportation’s KCARS database. After calculating the EPDO crash rates on paved and gravel roads in Kansas, results showed that paved surfaces were in general safer than gravel surfaces, which was taken into consideration while calculating the scaled values for safety. The final score was calculated by multiplying the weights of each factor and their respective scaled values. Roadway surface type with higher score is the preferred alternative for a road section under consideration. A computer-based program was created as a user interface, using Visual Studio, to carry out all complex calculations for determining LCC and VOC considering local variations. The program also helped determine final total scores for paved and gravel roads by considering scaled values of all-important factors considered for conversion. Another approach using cost versus traffic volume showed that the break-even point for traffic volume decreased with an increased percentage of trucks and increased vehicle speeds. Thus, the developed guideline helps determine the best roadway surface type for any set of local conditions.

Objective: To explore adult cancer symptom management by home care nurses. Scoping review: A scoping review was conducted to describe interventions used by nurses for cancer symptom management in the home care setting. Five included studies revealed that home care nursing contributed to positive client- and system-level outcomes. Study: A mixed-methods descriptive study explored usability of a set of 13 cancer treatment-related symptom management protocols for nurses in the home care setting. Thirty-eight nurses in home care participated. Qualitative and quantitative data indicated the protocols were highly usable. Several barriers suggested they would be better used as resources to support and train nurses rather than documentation tools. Conclusions: Few studies have evaluated interventions for cancer symptom management by home care nurses. This set of protocols was well-received, but further research is required to determine their effectiveness and interventions for implementing with home care nurses providing cancer symptom management.

Testing is one of the most important aspects in the development of new products. There are different types of testing a product can undergo, either hardware durability tests or software tests. Embedded systems are closely related to hardware and a key feature of them is the reliability and dependability. In order to assure that these features will remain intact no matter where the embedded systems operate it is very important to conduct standardized testing and give validation. The purpose of this thesis is to research the temperature testing procedure and develop a measurement guideline based on several key moments. The guideline is closely related to the standards and due to this reason some of the most frequently used standards are taken in consideration. The temperature measurement technology involves different tools or equipment. One interesting technology used for this purpose is the infrared technology through the investigation provided by the IR cameras. It is benefcial to integrate this technology in the contact measurements because it describes the temperature variation by colors, information which is very important in the first steps of the test procedure.

This Thesis is aimed at evaluating the options of renovation for an existing residential building to make it more energy efficient. The various aspects in the basic structures of residential homes are discussed in order to help the user identify the areas of the house for which renovation is required to improve the energy efficiency of the building. These aspects include doors, roof and wall in addition to various systems of electrical wiring, mechanical systems of ventilation, heating and cooling and plumbing systems for the efficient flow of water throughout the house. The renovation options have been described in detail to provide as many possibilities to the user as possible. The building taken for renovation is a 1953 suburban home which has been awarded the honor of being the first building to be labeled as Zero Energy Home in its vicinity. This has made the home so efficient that its expenditure of energy has become equivalent to its energy generation, therefore, cancelling each other out and creating an estimate of zero energy.

京都大学 / 0048 / 新制・課程博士 / 博士(社会健康医学) / 甲第22383号 / 社医博第105号 / 新制||社||医11(附属図書館) / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 古川 壽亮, 教授 川上 浩司, 教授 滝田 順子 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DFAM

No description available.

Guideline development processes influence the quality of clinical guidelines. The aim of this study was to use the AGREE II instrument to evaluate the variability of the quality of selected guidelines, to determine a baseline for the quality of current guidelines and determine whether guidelines demonstrated good standard practice during their development. The AGREE II instrument was used to assess a selection of guidelines published between January 2012 and June 2013. Eleven guidelines were selected for review. Overall, guidelines scored highest in domain 1 (Scope and purpose) and 4 (Clarity of presentation); and lowest in domain 3 (Rigour of development) and 6 (Editorial independence) with the overall assessment score of three out of seven. The study demonstrated that the quality of guidelines was variable and that there are deficiencies in the guideline development process. The results from this study provide a baseline to measure the quality of future guidelines. / Dissertation (MSc)--University of Pretoria, 2014. / tm2015 / School of Health Systems and Public Health (SHSPH) / MSc / Unrestricted

The purpose of sustainability reports is to represent the progress of a company’s sustainability effort and status to stakeholders. There is a need for stakeholders to benchmark sustainability performance of companies. The objective of this research was to find evidence that the GRI Application Level used in the ranking GRI compliant sustainability reports, is an indicator of financial performance for companies trading on the JSE in South Africa.The results will show that there is no evidence to show that the GRI Applications Level is an indicator of financial performance. The consequence of this evidence is that the lack of adequate benchmark standards can de-motivate companies to strive for higher sustainability performance. / Dissertation (MBA)--University of Pretoria, 2012. / Gordon Institute of Business Science (GIBS) / unrestricted