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PubMed2006

Partnership as an ethical model for medical research in developing countries: the example of the "implementation trial".

The existing model for ethical review of medical research consists primarily of regulations designed to prevent exploitation of participants. This model may fail when reviewing other ethical obligations, particularly the responsibility to provide valuable knowledge to society. Such failure is most apparent in developing countries, in which many stakeholders lack incentives or power to uphold society's interests. An alternative ethical model is that of partnership, which actively involves all partners during ethical review and aims to secure partners' best interests through compromise. Unlike the existing "regulatory" model, the partnership model effectively addresses ethical obligations to provide positive benefits to society. For the partnership model to be effective, power must be shared among partners; thus, the partnership model can be harmonised with the "regulatory" model through explicit consideration of power structures. One opportunity for crafting power balance in developing countries is apparent in "implementation trials"-randomised trials motivated by and integrated into the implementation of long term public health interventions. Given the failings of the existing ethical review model, alternative models-for example, partnership-and means to balance power-for example, implementation trials-must be explored to ensure that medical research provides knowledge of value to societies in the developing world.

Cooperative Behavior↗

PubMed2006

Cross shift changes in lung function among bar and restaurant workers before and after implementation of a smoking ban.

OBJECTIVE: To study possible cross shift effects of environmental tobacco smoke (ETS) on pulmonary function among bar and restaurant employees before and after the implementation of a smoking ban in Norway. METHODS: The study included 93 subjects employed in 13 different establishments in Oslo. They were examined at the beginning and end of a workshift both while ETS exposure was present and when smoking was banned. The mean exposure level of nicotine and total dust before the ban was 28 microg/m3 (range 3-65) and 275 microg/m3 (range 81-506), respectively. Following the smoking ban, the mean level of nicotine and total dust was 0.6 mug/m3 and 77 microg/m3, respectively. Assessment of lung function included dynamic lung volumes and flows. RESULTS: The cross shift reduction in forced vital capacity (FVC) among 69 subjects participating in both examinations changed from 81 ml (SD 136) during exposure to ETS to 52 ml (SD 156) (p = 0.24) following the smoking ban. The reduction in forced expired volume in one second (FEV1) during a workshift, was borderline significantly reduced when comparing the situation before and after the intervention, by 89 ml (SD = 132) compared to 46 ml (SD = 152) (p = 0.09), respectively. The reduction in forced mid-expiratory flow rate (FEF25-75%) changed significantly from 199 ml/s (SD = 372) to 64 ml/s (SD = 307) (p = 0.01). Among 26 non-smokers and 11 asthmatics, the reduction in FEV1 and FEF25-75% was significantly larger during ETS exposure compared to after the smoking ban. There was an association between the dust concentration and decrease in FEF25-75% before the ban among non-smokers (p = 0.048). CONCLUSIONS: This first study of cross shift changes before and after the implementation of a smoking ban in restaurants and bars shows a larger cross shift decrease in lung function before compared with after the implementation of the ban.

Adult↗

PubMed1996

Clinical guidelines and their implementation.

Within the UK there has been increasing interest in the development and implementation of guidelines, as the emphasis on clinical effectiveness is gathering momentum. This paper outlines some of the practical issues encountered in developing and implementing guidelines, based on experiences within Liverpool. Developing local guidelines can be a lengthy process, but that process is not a waste of time if it means there is more likely to be compliance in the end. Dissemination of guidelines alone is not enough; it needs to be combined with an appropriate implementation strategy. There is a danger of primary care being overloaded with new guidelines; there needs to be a timed strategy for their introduction. More imaginative thought needs to be put into the marketing of new ideas in order to change practice. We need to encourage the ethos amongst healthcare professionals of expecting to have to constantly update knowledge and practice.

England↗

PubMed2005

Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR.

BACKGROUND: Pilot studies of complex interventions such as a team checklist are an essential precursor to evaluating how these interventions affect quality and safety of care. We conducted a pilot implementation of a preoperative team communication checklist. The objectives of the study were to assess the feasibility of the checklist (that is, team members' willingness and ability to incorporate it into their work processes); to describe how the checklist tool was used by operating room (OR) teams; and to describe perceived functions of the checklist discussions. METHODS: A checklist prototype was developed and OR team members were asked to implement it before 18 surgical procedures. A research assistant was present to prompt the participants, if necessary, to initiate each checklist discussion. Trained observers recorded ethnographic field notes and 11 brief feedback interviews were conducted. Observation and interview data were analyzed for trends. RESULTS: The checklist was implemented by the OR team in all 18 study cases. The rate of team participation was 100% (33 vascular surgery team members). The checklist discussions lasted 1-6 minutes (mean 3.5) and most commonly took place in the OR before the patient's arrival. Perceived functions of the checklist discussions included provision of detailed case related information, confirmation of details, articulation of concerns or ambiguities, team building, education, and decision making. Participants consistently valued the checklist discussions. The most significant barrier to undertaking the team checklist was variability in team members' preoperative workflow patterns, which sometimes presented a challenge to bringing the entire team together. CONCLUSIONS: The preoperative team checklist shows promise as a feasible and efficient tool that promotes information exchange and team cohesion. Further research is needed to determine the sustainability and generalizability of the checklist intervention, to fully integrate the checklist routine into workflow patterns, and to measure its impact on patient safety.

Communication↗

PubMed2006

Reduced morbidity for elderly patients with a hip fracture after implementation of a perioperative evidence-based clinical pathway.

BACKGROUND: Hip fractures, common in the elderly population, result in significant morbidity and mortality. A study was undertaken to determine how an evidence based clinical pathway (CP) for treatment of elderly patients with hip fracture affected morbidity, in-hospital mortality, and health service utilization. METHODS: A pre-post study design using two population based inception cohorts of hip fracture patients aged > or =65 years was used. The control group (n = 678) was enrolled between July 1996 and September 1997 before implementation of the pathway and the CP group (n = 663) was enrolled between July 1999 and September 2000 following pathway implementation. Chart reviews were completed during study time frames to determine complications, mortality, and health service utilization. RESULTS: Only nine patients (1%) in the CP group experienced postoperative congestive heart failure compared with 37 (5%) control patients (p<0.001). Postoperative cardiac arrythmias were significantly lower in the CP group than in the control group (8 (1%) v 36 (5%); p<0.001). Postoperative delirium occurred in 22% of the CP group and 51% of the control group (p<0.001). There was no difference in risk adjusted in-hospital mortality between the two groups. Overall length of stay (LOS) and costs were unchanged between the groups; however, hospital LOS increased while rehabilitation LOS decreased in the CP group. CONCLUSION: Implementation of an evidence based clinical pathway reduced postoperative morbidity and did not affect in-hospital mortality or overall costs of inpatient care. The effect of changing trends in medical care cannot be ruled out, but the reduction in complications in several clinical areas lends support to the positive impact of the clinical pathway. Perioperative CP is one successful management approach for this fragile patient population as patient morbidity was reduced without negatively affecting resource utilization.

Aged↗

PubMed1998

Enabling the implementation of evidence based practice: a conceptual framework.

The argument put forward in this paper is that successful implementation of research into practice is a function of the interplay of three core elements--the level and nature of the evidence, the context or environment into which the research is to be placed, and the method or way in which the process is facilitated. It also proposes that because current research is inconclusive as to which of these elements is most important in successful implementation they all should have equal standing. This is contrary to the often implicit assumptions currently being generated within the clinical effectiveness agenda where the level and rigour of the evidence seems to be the most important factor for consideration. The paper offers a conceptual framework that considers this imbalance, showing how it might work in clarifying some of the theoretical positions and as a checklist for staff to assess what they need to do to successfully implement research into practice.

Evidence-Based Medicine↗

PubMed1998

Implementing smoking bans in American hospitals: results of a national survey.

OBJECTIVES: To determine how well hospitals complied with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) tobacco control standards, which required banning smoking in hospital buildings; to explore issues involved in developing and implementing smoking bans; and to ascertain the perceived success of the policies. DESIGN: Postal survey conducted January through June 1994. PARTICIPANTS: Stratified random sample of American hospitals surveyed by JCAHO (n = 1055). MAIN OUTCOME MEASURES: Enacting smoking policies more restrictive than the JCAHO standard; the respondent's judgment of the relative success of the hospital's smoking policy. RESULTS: More than 96% of hospitals complied with the smoking ban standard; 41.4% enacted policies that were more restrictive than required by JCAHO. Several characteristics were associated with exceeding JCAHO requirements: location in a "non-tobacco state"; having fewer than 100 beds; location in a metropolitan statistical area; having unionsed employees; and having no psychiatric or substance abuse unit, favour having the same tobacco policy in psychiatry and substance abuse units as the rest of the hospital. More than 95% of respondents viewed their hospital's policy as successful. The JCAHO requirements and concern for employees' health were the major forces influencing hospitals to go smoke-free. Negative employee morale and lack of acceptance by visitors and patients were the most commonly cited barriers to overcome when implementing smoke-free policies. CONCLUSIONS: Smoking bans were successfully implemented in American hospitals, with many restricting smoking beyond the JCAHO standard. Other industries wishing to follow hospitals' lead would be most likely to succeed in the context of a social norm favouring a smoking ban and regulation by an outside agency.

Health Policy↗

PubMed2001

A multithreaded parallel implementation of a dynamic programming algorithm for sequence comparison.

This paper discusses the issues involved in implementing a dynamic programming algorithm for biological sequence comparison on a general-purpose parallel computing platform based on a fine-grain event-driven multithreaded program execution model. Fine-grain multithreading permits efficient parallelism exploitation in this application both by taking advantage of asynchronous point-to-point synchronizations and communication with low overheads and by effectively tolerating latency through the overlapping of computation and communication. We have implemented our scheme on EARTH, a fine-grain event-driven multithreaded execution and architecture model which has been ported to a number of parallel machines with off-the-shelf processors. Our experimental results show that the dynamic programming algorithm can be efficiently implemented on EARTH systems with high performance (e.g., speedup of 90 on 120 nodes), good programmability and reasonable cost.

Algorithms↗

PubMed2001

A new implementation and detailed study of breakpoint analysis.

Phylogenies derived from gene order data may prove crucial in answering some fundamental open questions in biomolecular evolution. Yet very few techniques are available for such phylogenetic reconstructions. One method is breakpoint analysis, developed by Blanchette and Sankoff for solving the "breakpoint phylogeny." Our earlier studies confirmed the usefulness of this approach, but also found that BPAnalysis, the implementation developed by Sankoff and Blanchette, was too slow to use on all but very small datasets. We report here on a reimplementation of BPAnalysis using the principles of algorithmic engineering. Our faster (by 2 to 3 orders of magnitude) and flexible implementation allowed us to conduct studies on the characteristics of breakpoint analysis, in terms of running time, quality, and robustness, as well as to analyze datasets that had so far been considered out of reach. We report on these findings and also discuss future directions for our new implementation.

Algorithms↗

PubMed2000

Implementation of a pulse coupled neural network in FPGA.

The Pulse Coupled neural network, PCNN, is a biologically inspired neural net and it can be used in various image analysis applications, e.g. time-critical applications in the field of image pre-processing like segmentation, filtering, etc. a VHDL implementation of the PCNN targeting FPGA was undertaken and the results presented here. The implementation contains many interesting features. By pipelining the PCNN structure a very high throughput of 55 million neuron iterations per second could be achieved. By making the coefficients re-configurable during operation, a complete recognition system could be implemented on one, or maybe two, chip(s). Reconsidering the ranges and resolutions of the constants may save a lot of hardware, since the higher resolution requires larger multipliers, adders, memories etc.

Analog-Digital Conversion↗

PubMed2000

VLSI implementation of neural networks.

Currently, fuzzy controllers are the most popular choice for hardware implementation of complex control surfaces because they are easy to design. Neural controllers are more complex and hard to train, but provide an outstanding control surface with much less error than that of a fuzzy controller. There are also some problems that have to be solved before the networks can be implemented on VLSI chips. First, an approximation function needs to be developed because CMOS neural networks have an activation function different than any function used in neural network software. Next, this function has to be used to train the network. Finally, the last problem for VLSI designers is the quantization effect caused by discrete values of the channel length (L) and width (W) of MOS transistor geometries. Two neural networks were designed in 1.5 microm technology. Using adequate approximation functions solved the problem of activation function. With this approach, trained networks were characterized by very small errors. Unfortunately, when the weights were quantized, errors were increased by an order of magnitude. However, even though the errors were enlarged, the results obtained from neural network hardware implementations were superior to the results obtained with fuzzy system approach.

Computer Simulation↗

PubMed2000

Automating parallel implementation of neural learning algorithms.

Neural learning algorithms generally involve a number of identical processing units, which are fully or partially connected, and involve an update function, such as a ramp, a sigmoid or a Gaussian function for instance. Some variations also exist, where units can be heterogeneous, or where an alternative update technique is employed, such as a pulse stream generator. Associated with connections are numerical values that must be adjusted using a learning rule, and and dictated by parameters that are learning rule specific, such as momentum, a learning rate, a temperature, amongst others. Usually, neural learning algorithms involve local updates, and a global interaction between units is often discouraged, except in instances where units are fully connected, or involve synchronous updates. In all of these instances, concurrency within a neural algorithm cannot be fully exploited without a suitable implementation strategy. A design scheme is described for translating a neural learning algorithm from inception to implementation on a parallel machine using PVM or MPI libraries, or onto programmable logic such as FPGAs. A designer must first describe the algorithm using a specialised Neural Language, from which a Petri net (PN) model is constructed automatically for verification, and building a performance model. The PN model can be used to study issues such as synchronisation points, resource sharing and concurrency within a learning rule. Specialised constructs are provided to enable a designer to express various aspects of a learning rule, such as the number and connectivity of neural nodes, the interconnection strategies, and information flows required by the learning algorithm. A scheduling and mapping strategy is then used to translate this PN model onto a multiprocessor template. We demonstrate our technique using a Kohonen and backpropagation learning rules, implemented on a loosely coupled workstation cluster, and a dedicated parallel machine, with PVM libraries.

Algorithms↗

PubMed2006

Implementation of online radiology quality assurance reporting system for performance improvement: initial evaluation.

PURPOSE: To evaluate an online system developed and implemented for reporting and managing quality assurance (QA) events occurring in a radiology department. MATERIALS AND METHODS: This HIPAA-compliant study had institutional review board approval; informed consent was not required. Using repeated plan-do-study-act cycles, a radiology quality management team applied a 10-step process to implement an online reporting system. The system permits remote submission of cases by staff members. The number of weekly submissions to the system over a 9-month period was evaluated and compared with that for the preceding 6 months by using the Mann-Whitney test. Sources and nature of data, actions initiated, and final outcomes were also analyzed. Recorded data included forum of discussion, dimension of care, action items, monitoring of follow-up and compliance, and notification status. RESULTS: During the first 9 months of implementation, 605 cases were submitted (mean, 21.4 cases per week), a significant increase (P < .005) compared with the preceding 6 months (mean, 3.2 cases per week). Cases, which were submitted by residents (121 cases [20.0%]), fellows (94 cases [15.5%]), faculty members (319 cases [52.7%]), or technologists (54 cases [8.9%]), reported technical (33.1%) or administrative (8.0%) issues. The 329 clinical cases (54.4%) included 60 errors in communication (18.2%), 67 errors in interpretation (20.4%), 78 diagnostic delays (23.7%), 99 missed diagnoses (30.1%), and 54 procedural complications (16.4%); some cases were in more than one category. Twenty-three cases (3.8%) resulted in submission-related QA projects, and 69 cases (11.4%) resulted in individuals or sections of the hospital undergoing additional training. CONCLUSION: A secure online QA reporting system promotes reporting of QA events and serves as a database for identifying and managing trends, initiating performance improvement projects, and providing feedback to staff members who submit cases.

Health Services Research↗

PubMedDate not supplied

The costs of implementing the 1999 Canadian Asthma Consensus Guidelines recommendation of asthma education and spirometry for the family physician.

BACKGROUND: National and international asthma guidelines recommend that patients with asthma be provided with asthma education and spirometry as a component of enhanced asthma care. The cost of implementing these interventions in family physician practices is not known. OBJECTIVE: The objective of the present study was to determine the cost of providing recommended asthma care to adult patients in the family practice setting. METHODS: The present study was conducted using three scenarios of care in family practice. Small, medium and large asthmatic patient populations were used. The incremental costs of implementing enhanced asthma care based on the Canadian Asthma Consensus Guidelines, including the provision of spirometry and asthma education in both group and individual sessions, and the resources required for these interventions were calculated for each scenario. RESULTS: For a physician with 50 asthmatic patients, the cost of providing enhanced asthma care with spirometry and group education sessions was approximately 78 dollars per patient in the first year of implementation. For individual sessions, the cost increased to 100 dollars per patient for the first year. If the physician had 100 asthmatic patients, the per patient cost would decrease; however, the overall cost of the program would be 7,000 dollars. CONCLUSIONS: The costs of providing enhanced asthma care are significant. In most cases, physicians are inadequately reimbursed (or not reimbursed) for these interventions. In light of the evidence of the effectiveness of these interventions, health insurance plans should consider adding these services to fee schedules.

Asthma↗

PubMed2006

Implementation of guidelines improves the standard of care: the Viennese registry on reperfusion strategies in ST-elevation myocardial infarction (Vienna STEMI registry).

BACKGROUND: The purpose of this study was to determine whether implementation of recent guidelines improves in-hospital mortality from acute ST-elevation myocardial infarction (STEMI) in a metropolitan area. METHODS AND RESULTS: We organized a network that consisted of the Viennese Ambulance Systems, which is responsible for diagnosis and triage of patients with acute STEMI, and 5 high-volume interventional cardiology departments to expand the performance of primary percutaneous catheter intervention (PPCI) and to use the fastest available reperfusion strategy in STEMI of short duration (2 to 3 hours from onset of symptoms), either PPCI or thrombolytic therapy (TT; prehospital or in-hospital), respectively. Implementation of guidelines resulted in increased numbers of patients receiving 1 of the 2 reperfusion strategies (from 66% to 86.6%). Accordingly, the proportion of patients not receiving reperfusion therapy dropped from 34% to 13.4%, respectively. PPCI usage increased from 16% to almost 60%, whereas the use of TT decreased from 50.5% to 26.7% in the participating centers. As a consequence, in-hospital mortality decreased from 16% before establishment of the network to 9.5%, including patients not receiving reperfusion therapy. Whereas PPCI and TT demonstrated comparable in-hospital mortality rates when initiated within 2 to 3 hours from onset of symptoms, PPCI was more effective in acute STEMI of >3 but <12 hours' duration. CONCLUSIONS: Implementation of recent guidelines for the treatment of acute STEMI by the organization of a cooperating network within a large metropolitan area was associated with a significant improvement in clinical outcomes.

Aged↗

PubMed1995

An implementation of von Neumann's self-reproducing machine.

This article describes in detail an implementation of John von Neumann's self-reproducing machine. Self-reproduction is achieved as a special case of construction by a universal constructor. The theoretical proof of the existence of such machines was given by John von Neumann in the early 1950s [6], but was first implemented in 1994, by the author in collaboration with R. Nobili. Our implementation relies on an extension of the state-transition rule of von Neumann's original cellular automaton. This extension was introduced to simplify the design of the constructor. The main operations in our constructor can be mapped into operations of von Neumann's machine.

Artificial Intelligence↗

PubMed2006

Temporal decoding by phase-locked loops: unique features of circuit-level implementations and their significance for vibrissal information processing.

Rhythmic active touch, such as whisking, evokes a periodic reference spike train along which the timing of a novel stimulus, induced, for example, when the whiskers hit an external object, can be interpreted. Previous work supports the hypothesis that the whisking-induced spike train entrains a neural implementation of a phase-locked loop (NPLL) in the vibrissal system. Here we extend this work and explore how the entrained NPLL decodes the delay of the novel, contact-induced stimulus and facilitates object localization. We consider two implementations of NPLLs, which are based on a single neuron or a neural circuit, respectively, and evaluate the resulting temporal decoding capabilities. Depending on the structure of the NPLL, it can lock in either a phase- or co-phase-sensitive mode, which is sensitive to the timing of the input with respect to the beginning of either the current or the next cycle, respectively. The co-phase-sensitive mode is shown to be unique to circuit-based NPLLs. Concentrating on temporal decoding in the vibrissal system of rats, we conclude that both the nature of the information processing task and the response characteristics suggest that the computation is sensitive to the co-phase. Consequently, we suggest that the underlying thalamocortical loop should implement a circuit-based NPLL.

Animals↗

PubMed1993

Quality of care for hospitalized depressed elderly patients before and after implementation of the Medicare Prospective Payment System.

OBJECTIVE: The authors evaluated the impact of Medicare's Prospective Payment System on aspects of quality of care and outcomes for depressed elderly inpatients in acute-care general medical hospitals. METHOD: The depressed elderly inpatients (N = 2,746) were hospitalized in 297 acute-care general medical hospitals. The authors used a retrospective before-and-after design, controlling for differences over time in sickness at admission. Quality of care and outcomes were assessed through clinical review of explicit and implicit information in the medical records; secondary data sources provided information on postdischarge outcomes. RESULTS: After implementation of the prospective payment system 1) a higher percentage of patients had clinically appropriate acute-care admissions; 2) the initial assessment of psychological status by the treating provider was more complete; 3) the quality of psychotropic medication management, as rated by the study psychiatrists, improved; 4) the rates of any inpatient medical or psychiatric complication, of discharge to another hospital or a nursing home, and of inpatient readmission declined; and 5) there was no marked change in the percentage of patients rated by study clinicians as having acceptable overall clinical status at discharge or the rate of mortality 1 year after admission. CONCLUSIONS: After the implementation of the Medicare Prospective Payment System, the quality of care for depressed elderly inpatients improved and there was no marked increase in adverse clinical outcomes. Despite these gains, after implementation the quality of care was moderate at best and over one-third of the patients had unacceptable clinical status at discharge.

Aged↗