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Work redesign: a case study.

This paper details the implementation experience of a work redesign process in a neurosurgical setting in a large community hospital, from conception to "live" demonstration. First, the concept of work redesign is explored, in relation to its underpinnings and its application in the health care setting. Work redesign has two elements: first, it involves the reconfiguration in the job or work role itself and second, a change in the way work is actually performed. Next, the model as it was conceived by the organization, is described. While the "high level" or organizational-wide design was constructed by a central steering team, we recognized the need to customize the model to the unique needs of each clinical service area. Finally, implementation is discussed, including structure, process, evaluation and critical success factors.

Canada↗

A 4-year history of work redesign in two ICUs.

To understand caregiver activities and their associated costs, two intensive care units (ICUs) initiated a work redesign study. During 1 week each year, ICU employees recorded and summarized their activities in 5-minute blocks of time. Activities were analyzed; processes were evaluated and redesigned.

Critical Care↗

Five pitfalls of work redesign in acute care.

During work redesign in nursing units, five common pitfalls can emerge: moving too fast, failing to involve major stakeholders, discounting bargaining unit contracts, separating training classes and not defining desired outcomes. Suggestions on how to avoid these problems are given.

Collective Bargaining↗

Systems redesign in rehabilitation.

A performance improvement team overhauled its facility's rehabilitation systems. A rehabilitation care plan was revised and an integrated assessment reduced 29 pages of documentation to 17 pages. Case management goals and documentation are integrated into one care plan.

Community Participation↗

Use of physiological criteria for improving physical work conditions.

Physical work is still present in many countries, specially in developing ones. The physiological analysis of the work load could be conducted through two different ways, referring to his energetic cost and/or to the mechanical power of the human motor. The purpose of ergonomics is to organize any physical professional task in order to maintain the workers as much as possible inside the limits of a fatiguing activity. The process of fatigue affects differently a "general activity" and a "local work." If a worker is engaged in a general hard activity, like carrying a load or pushing a trolley, an increase of oxygen consumption or/and an acceleration of the heart rate could be observed. This latter, allowing to estimate the oxygen cost of the work, is more affected if the work is performed in a hot environment. In order to establish the ratio between the data observed at the work place and the maximal working capacity of the organism, it is possible to experiment with the physiological effects of transitory increases of the work stress, by increasing the load or/and the frequency of the repetition of the "unit" of work done. When the task could be described in terms of local work, the correct methodology is based upon the general rules established respectively for the static and the dynamic work. In both the cases, it is possible to determine the critical rate of the muscular activity, the part of the muscular capacity engaged at the work place and the probable time for local exhaustion, in order to limit the duration of each period of work. It should be remembered that 50 years ago, Lucien Brouha proposed that heart rate determinations at work be used as a criteria for a better organization of human work by a non-sophisticated method.

Biomechanical Phenomena↗

[Effect of mechanized work on the indicators of traumatism among lumberjacks].

The author has considered trauma from the point of view of three main indices: frequency, gravity and average duration of incapacity of each patient in days. An important conclusion is made that further progressive replacement of manual labour by mechanized one will influence positively the basic indices of traumatism in timber industry.

Burns↗

A layer-specific three-dimensional model for the simulation of balloon angioplasty using magnetic resonance imaging and mechanical testing.

A detailed understanding of the mechanical procedure of balloon angioplasty requires three-dimensional (3D) modeling and efficient numerical simulations. We have developed a 3D model for eight distinct arterial components associated with specific mechanical responses. The 3D geometrical model is based on in vitro magnetic resonance imaging of a human stenotic postmortem artery and is represented by nonuniform rational B-spline surfaces. Mechanical tests of the corresponding vascular tissues provide a fundamental basis for the formulation of large strain constitutive laws, which model the typical anisotropic, highly nonlinear, and inelastic mechanical characteristics under supraphysiological loadings. The 3D finite-element realization considers the balloon-artery interaction and accounts for vessel-specific axial in situ prestretches. 3D stress states of the investigated artery during balloon expansion and stent deployment were analyzed. Furthermore, we studied the changes of the 3D stress state due to model simplifications, which are characterized by neglecting axial in situ prestretch, assuming plane strain states, and isotropic material responses, as commonly utilized in previous works. Since these simplifications lead to maximum stress deviations of up to 600%-where even the stress character may interchange-the associated models are, in general, inappropriate. The proposed approach provides a tool that has the potential (i) to improve procedural protocols and the design of interventional instruments on a lesion-specific basis, and (ii) to determine postangioplasty mechanical environments, which may be correlated with restenosis responses.

Aged↗

[The methyleneblue reduction disc test (M.R.D.-test): a simplified method for the identification of Pseudomonas species (author's transl)].

The identification of Pseudomonas species in practice can be improved by testing the utilization of different organic compounds as single sources of carbon. The introduction of this kind of technique into routine laboratory work requires a simplification of the test system. In order to meet these requirements the methyleneblue reduction disc test (M.R.D.-test) had been developed. In this test discs loaded with different organic compounds are introduced into suspensions of the strain examined as single source of carbon. Before to these bacterial suspensions a mineral salts solution containing methyleneblue as a redox indicator had been added. With the help of this method the utilization of a large number of different organic compounds as single sources of carbon can be tested in a way which is neither laborious nor time consuming. The disc once prepared can be stored for some time, single strains can be tested without any difficulty as they are isolated during routine laboratory work.

Culture Media↗

A modified procedure for the rapid preparation of efficiently transporting vesicles from small intestinal brush border membranes. Their use in investigating some properties of D-glucose and choline transport systems.

We have worked out a simplification of the procedure described by Schmitz et al. (Biochim. Biophys. Acta (1973) 323, 98--112) for the preparation of brush border membranes from small intestine. The procedure ultimately adopted is simple, rapid, does not necessarily require scraping and can be started from fresh or frozen material. It can be scaled up easily, allowing a quick production of large amounts of brush border membrane vesicles. These vesicles prove to be excellently suited for transport studies, as suggested by our measurements of D-glucose transport. Using these vesicles, the mode of choline transport across the brush border membrane was also investigated. Choline transport was found to occur by a saturable component with a Km of 83 +/- 4 micrometer (at 20 degrees C) and by a non-saturable component. It is independent of the presence of Na+ and appears to be non-electrogenic.

Animals↗

An improved automated fluorimetric method for determination of histamine.

The automated continuous flow system for the extraction and fluorimetric analysis of histamine based on the principle of Shore et al. (1959) has been improved. With lower consumption of reagents and further simplification of the working conditions, histamine can be determined quantitatively in a routine fashion in aqueous samples, with or without protein content, up to a concentration of approximately 0.1 ng/ml. The rate of analysis is 30 samples/h.

Animals↗

Deep-water waves in the cochlea.

In order to obtain physical insight from a mathematical solution of the cochlear mechanics problem, a delicate balance is required between simplifications and refinements in modeling. For the study of the transition of long to short waves (deep-water waves) a closed-form solution is advantageous; this can, however, only be obtained at the cost of further simplification. In previous work the course of the impedance function z(x) was, therefore, reduced to the extreme: in the neighbourhood of the resonance location z(x) was assumed to be a linear function of x - the so-called 'straight-line approximation'. This restriction is removed in the present paper. A 'hyperbolical approximation' of the impedance function z(x) is introduced and it is shown that with this function the two-dimensional cochlea model can be solved in closed form. The computation results show that, for not too large values of the damping parameter delta, the response in the neighbourhood of the resonance location is almost as well represented by the formerly used 'straight-line approximation' as by the 'hyperbolic approximation'. Hence the principal aspects of cochlear resonance are well brought to light with the 'straight-line approximation'. This implies that in the case under consideration the dominant part played by short waves is confirmed. When a larger range of x values is to be considered, the hyperbolic approximation is advantageous. The computed response functions agree better with experimental data from the literature. However, it is clear that really satisfactory agreement seems not possible with a two-dimensional model.

Basilar Membrane↗

Experimental models of temporary normothermic liver ischemia.

Hepatic ischemia/reperfusion injury has so far been investigated in various experimental models. A clinical transfer of experimental results is, however, problematic because of anatomical and physiological differences and also the inevitable simplification of experimental work. The choice of model must therefore be adapted to the clinical question to be answered. The simplest procedure for inducing normothermic ischemia is to clamp the hepatoduodenal ligament. Models that do not avert portal congestion are regarded as unsuitable. Our current understanding of the pathogenesis of ischemia/reperfusion injury depends mainly on studies whose authors have investigated either global liver ischemia with a portocaval shunt, spleen transposition and in the isolated perfused system, or partial ischemia. This review is a critical examination of various approaches to the study of normothermic hepatic ischemia in experimental animals.

Age Factors↗

The lymphocyte transformation test in the diagnosis of drug hypersensitivity.

Diagnosis of drug hypersensitivity is difficult, as an enormous amount of different drugs can elicit various immune-mediated diseases with distinct pathomechanism. The lymphocyte transformation test (LTT) measures the proliferation of T cells to a drug in vitro--from which one concludes to a previous in vivo reaction due to a sensitization. This concept of the LTT has been confirmed by the generation of drug-specific T-cell clones and the finding that drugs can directly interact with the T-cell receptor, without previous metabolism or need to bind to proteins. In this review, technical aspects and usefulness of this test for the diagnosis of drug hypersensitivity are discussed. The main advantage of this test is its applicability with many different drugs in different immune reactions, as drug-specific T cell are almost always involved in drug hypersensitivity reactions. Its main disadvantages are that an in vitro proliferation of T cells to a drug is difficult to transfer to the clinical situation and that the test per se is rather cumbersome and technically demanding. In addition, its sensitivity is limited (for beta-lactam allergy it is in the range of 60-70%), - although at least in our hands - it is higher than of other tests for drug hypersensitivity diagnosis. Consequently, drug hypersensitivity diagnosis needs to rely on a combination of history and different tests, as none of the single tests available has per se a sufficiently good sensitivity. Within this setting, the LTT has proven to be a useful test for the diagnosis of drug hypersensitivity reactions and helped to better understand these reactions. Further work on the simplification of this test and systematic evaluation of its sensitivity and specificity in some main groups of drugs are necessary to make this test more widely available.

Drug Hypersensitivity↗

Recommended Childhood Immunization Schedule--United States, January-June 1996.

In January 1995, the Recommended Childhood Immunization Schedule, developed by the Advisory Committee on Immunization Practices (ACIP) the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP), was published. This unified schedule represented the first such schedule developed through a collaborative process among the recommending groups, the pharmaceutical manufacturing industry, and the Food and Drug Administration. This process is intended to maintain a common childhood immunization schedule and to work toward further simplification of the schedule. The Recommended Childhood Immunization Schedule--United States, January-June 1996 (Figure 1) has been updated by these groups to incorporate newly licensed and/or recommended vaccines and to clarify specific issues. Since publication of the schedule in 1995, Varicella Zoster Virus Vaccine (Var) has been licensed, and recommendations for adolescent hepatitis B vaccination have been developed. The following changes are incorporated into the Recommended Childhood Immunization Schedule.

Adolescent↗

SUBJECT HEADINGS IN THE WELLCOME HISTORICAL MEDICAL LIBRARY.

The strength and unity of the medical library profession spring largely from the existence of the National Library of Medicine. Its publications promise to bring much closer the standardization and consistency still lacking to the world of medical subject headings. The Wellcome Library headings are similar to those listed in the National Library of Medicine Subject Heading Authority List of 1960. However, references and additional headings are made to cover (1) superseded terms, (2) historical phenomena with distinctive names which are peculiar to an epoch, (3) subjects from social, religious, or other branches of history, and (4) eponyms. Old texts often describe disease ambiguously or use terminology which has since been superseded. The catalogue is in three parts-topographical, biographical, and topical. The quarterly Current Work has certain simplifications (e.g., elimination of some subheadings), and has recently introduced references both to cut down needless duplication and to facilitate consultation by the reader.

England↗

[A contribution for conservative septal surgery (author's transl)].

The correction of the lower part of the septum serves the operation principle after Cottle. In the following work is a simplification shown to help discover the "Premaxilla-Area". Because of the possibility of mucous membrane perforation and irritation of the nasopalatinus nerve the building of an isolated inferior tunnel is purposely avoided. In any case the main aim is the least traumatical exposure of structures.

Cartilage↗

Several aspects of formation of auto-transplant and re-transplant vascular pedicle.

The purpose of the work was the simplification of technical side of autotransplantation and replantation by pre-preparation of vascular pedicle. 173 patients were observed and treated. Microsurgical autotransplantation of tissues was done in 29 cases, fingers autotransplantation in 44 cases (35 patients), fingers replantation in 66 cases (38 patients), replantation of thick parts of extremities in 34 cases (3 patients). Thoracodorsal flap on the neuro-vascular flap was transplntated in 16 cases, groin flap in 3 cases, deltoid flap -- in 3 cases, scapular flap -- in 1 case, saphenal -- 1 case, gracilis muscle in 3 cases, iliac crest flap in 2 cases, rib segment on vascular pedicle -- in 8 cases. Rib segment was transplanted as an isolated and with pre-prepared thoracodorsal bone-soft tissue complex also. II toe-finger and II-III toe-fingers block were transplanted for the abnormalities of the hand. Good and satisfactory functional and aesthetic results were obtained in all cases of autotransplantation and replantation. Original method of anastomosing of vessels was used in vein transplantation. We could simplify and increased the number of good results of operations by pre-preparing vascular pedicle. The results of treatment were improved by optimal election of donor site and preliminary forming of vascular pedicle of flaps and replants.

Anastomosis, Surgical↗

Interactions and spatial arrangement of spin-labeled NAD+ bound to glyceraldehyde-3-phosphate dehydrogenase. Comparison of EPR and X-ray modeling data.

The spatial arrangement of coenzyme NAD+ in remote and adjacent binding sites in various stoichiometric complexes with tetrameric glyceraldehyde-3-phosphate dehydrogenase from rabbit muscle was examined via EPR spectroscopy. An adenosine N6-15N,2H17 spin-labeled derivative of coenzyme NAD+ (SL-NAD+) was chemically synthesized for this work. The spectral simplifications and narrow line widths afforded by 15N and 2H substitution enabled experimental EPR spectra to be deconvoluted into their three component spectra: (a) unbound coenzyme, (b) bound coenzyme without adjacent site occupied, and (c) bound coenzyme with adjacent site occupied. Binding of SL-NAD+ in adjacent active centers of R axis-related subunits resulted in resolved dipolar interactions which characterized intersubunit distances. Binding to distant subunits related by the P and Q axes gave no dipolar interaction. Once the first NAD+ site was occupied, EPR spectra at various stoichiometries provided evidence for nonpreferential spatial binding of SL-NAD+ to the three unoccupied sites. EPR spectral simulations indicated a separation of 12.8 A for the unpaired electrons of spin label moieties of R axis-related coenzymes. Molecular modeling based on x-ray crystallographic data predicted 11-13 A. The angles and distance relating to interacting spin-labels were calculated from atomic coordinates based on molecular modeling of both anti-anti and anti-syn (adenine-ribose) conformations of SL-NAD+. Computer-generated line shapes indicated best agreement with experimental EPR results when the anti-anti geometry was employed. Comparison of EPR spectra from soluble and ammonium sulfate-precipitated enzymes indicated that the NAD+-binding domains are positioned equivalently in the two physical states. Since the observed dipolar line shapes are critically dependent on the distance and geometry relating to the interacting SL-NAD+, these data provide direct evidence for a high degree of conservation of quaternary structure of the enzyme in the hydrated crystalline state. Studies on the enzyme isolated from human erythrocytes also indicated a close correlation with the rabbit muscle enzyme in both the arrangement of NAD+-binding domains and negative cooperativity of coenzyme binding.

Animals↗