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Paramedics Providing Palliative Care at Home was launched in two provinces, including a new clinical practice guideline, database, and paramedic training. The aim of this study was to evaluate patient/family satisfaction and paramedic comfort and confidence.
In Part A, we gathered perspectives of patients/families via surveys mailed at enrolment and telephone interviews after an encounter. Responses were reported descriptively and by thematic analysis. In Part B, we surveyed paramedics online pre- and 18 months post-launch. Comfort and confidence were scored on a 4-point Likert scale, and attitudes on a 7-point Likert scale, reported as the median (interquartile range [IQR]); analysis with Wilcoxon ranked sum/thematic analysis of free text.
In Part A, 67/255 (30%) enrolment surveys were returned. Three themes emerged: fulfilling wishes, peace of mind, and feeling prepared for emergencies. In 18 post-encounter interviews, four themes emerged: 24/7 availability, paramedic professionalism and compassion, symptom relief, and a plea for program continuation. Thematic saturation was reached with little divergence. In Part B, 235/1255 (18.9%) pre- and 267 (21.3%) post-surveys were completed. Comfort with providing palliative care without transport improved post launch (p = < 0.001) as did confidence in palliative care without transport (p = < 0.001). Respondents strongly agreed that all paramedics should be able to provide basic palliative care.
After implementation of the multifaceted Paramedics Providing Palliative Care at Home Program, paramedics describe palliative care as important and rewarding. The program resulted in high patient/family satisfaction; simply registering provides peace of mind. After an encounter, families particularly noted the compassion and professionalism of the paramedics.
Loess is widespread over Alaska, and its accumulation has traditionally been associated with glacial periods. Surprisingly, loess deposits securely dated to the last glacial period are rare in Alaska, and paleowind reconstructions for this time period are limited to inferences from dune orientations. We report a rare occurrence of loess deposits dating to the last glacial period, ~19 ka to ~12 ka, in the Yukon-Tanana Upland. Loess in this area is very coarse grained (abundant coarse silt), with decreases in particle size moving south of the Yukon River, implying that the drainage basin of this river was the main source. Geochemical data show, however, that the Tanana River valley to the south is also a likely distal source. The occurrence of last-glacial loess with sources to both the south and north is explained by both regional, synoptic-scale winds from the northeast and opposing katabatic winds that could have developed from expanded glaciers in both the Brooks Range to the north and the Alaska Range to the south. Based on a comparison with recent climate modeling for the last glacial period, seasonality of dust transport may also have played a role in bringing about contributions from both northern and southern sources.
Healthcare provider hands are an important source of intraoperative bacterial transmission events associated with postoperative infection development.
To explore the efficacy of a novel hand hygiene improvement system leveraging provider proximity and individual and group performance feedback in reducing 30-day postoperative healthcare-associated infections via increased provider hourly hand decontamination events.
Randomized, prospective study.
Dartmouth-Hitchcock Medical Center in New Hampshire and UMass Memorial Medical Center in Massachusetts.
Patients undergoing surgery.
Operating room environments were randomly assigned to usual intraoperative hand hygiene or to a personalized, body-worn hand hygiene system. Anesthesia and circulating nurse provider hourly hand decontamination events were continuously monitored and reported. All patients were followed prospectively for the development of 30-day postoperative healthcare-associated infections.
A total of 3,256 operating room environments and patients (1,620 control and 1,636 treatment) were enrolled. The mean (SD) provider hand decontamination event rate achieved was 4.3 (2.9) events per hour, an approximate 8-fold increase in hand decontamination events above that of conventional wall-mounted devices (0.57 events/hour); P<.001. Use of the hand hygiene system was not associated with a reduction in healthcare-associated infections (odds ratio, 1.07 [95% CI, 0.82–1.40], P=.626).
The hand hygiene system evaluated in this study increased the frequency of hand decontamination events without reducing 30-day postoperative healthcare-associated infections. Future work is indicated to optimize the efficacy of this hand hygiene improvement strategy.
Offload delay is a prolonged interval between ambulance arrival in the emergency department (ED) and transfer of patient care, typically occurring when EDs are crowded. The offload zone (OZ), which manages ambulance patients waiting for an ED bed, has been implemented to mitigate the impact of ED crowding on ambulance availability. Little is known about the safety or efficiency. The study objectives were to process map the OZ and conduct a hazard analysis to identify steps that could compromise patient safety or process efficiency.
A Health Care Failure Mode and Effect Analysis was conducted. Failure modes (FM) were identified. For each FM, a probability to occur and severity of impact on patient safety and process efficiency was determined, and a hazard score (probability X severity) was calculated. For any hazard score considered high risk, root causes were identified, and mitigations were sought.
The OZ consists of six major processes: 1) patient transported by ambulance, 2) arrival to the ED, 3) transfer of patient care, 4) patient assessment in OZ, 5) patient care in OZ, and 6) patient transfer out of OZ; 78 FM were identified, of which 28 (35.9%) were deemed high risk and classified as impact on patient safety (n=7/28, 25.0%), process efficiency (n=10/28, 35.7%), or both (n=11/28, 39.3%). Seventeen mitigations were suggested.
This process map and hazard analysis is a first step in understanding the safety and efficiency of the OZ. The results from this study will inform current policy and practice, and future work to reduce offload delay.
A triple hurdle model estimates cattle farmer willingness to adopt or expand prescribed grazing on pasture in the United States in response to a hypothetical incentive program. Interest in adoption/expansion is estimated first, then willingness to participate in the program, followed by intensity of participation measured as additional acres enrolled. The supply elasticity of enrolled acres with respect to the incentive is 0.13. Nonpecuniary factors inter alia farmer sentiment about stewardship, current farm management practices, farm location, and education are associated with farmer willingness to participate and with participation intensity.
State programs promoting their agricultural products have proliferated in response to increased consumer interest in locally grown foods. Tennessee, for example, currently has two state-funded programs promoting its agricultural products. This study examines the factors associated with participation by Tennessee fruit and vegetable farmers in those programs. The results suggest that farmer participation is associated with farm income, use of extension resources, and fresh produce sales. These results should be of interest to anyone attempting to increase producer participation in such programs.
When a Master doth a thing a second time, lightly it is for the better.
George Gage to Sir Dudley Carleton, 1 November 1617
This chapter will probe early modern notions of creativity by considering the artistic activities, in and for England, of the most sought-after painter in seventeenth-century Europe – Peter Paul Rubens. The artist's busy workshop helped to satisfy the demand for his works, and as a result Rubens's English patrons, ranging from various dignitaries to Charles I himself, were the recipients of paintings with varying degrees of the master's own participation. An inquiry into Rubens's practice of delegating to studio assistants, and into the value placed by him and his British viewers on autography, will elucidate attitudes towards the manual aspects of creation. A related area of investigation will focus on the phenomenon of self-repetition in the artist's works for his English clients, some of which works were replicas of earlier compositions or reused motifs from previous inventions. Finally, a broader exploration of responses to self-replication, extending at times beyond the shores of England or the confines of painting, will bring to the fore the tensions inherent in early modern attitudes to art.
Replicas and Studio Hands
Although Rubens's stay in England as a diplomatic envoy dates to 1629–30, his relationship with English patrons had begun some thirteen years earlier when Sir Dudley Carleton, the English Ambassador to The Hague, had sought to trade a diamond chain for a hunt scene by the artist.
This book has its origins in an interdisciplinary conference of the same name, held at the University of Manchester in September 2008 as part of a four-year research project entitled ‘Musical Creativity in Restoration England’, which was funded by the Arts and Humanities Research Council in the UK. The conference brought together a group of seventeenth-century specialists including those working in cultural studies, print culture, the history of ideas, and of course historians of art, architecture, theatre, literature and music, to explore how we can seek to understand what it meant to be creative in the early modern period in England. Te symposium revealed the wide variety of approaches to studying creativity being taken by scholars and research students across the humanities, and led to exciting and fruitful cross-fertilization of ideas between its participants, resulting in discussions that in some cases have led to long-lasting research collaborations.
Tis book presents a selection of twelve essays that were developed from the twenty papers given at the conference. In selecting this group, the editors have sought to include a representative sample of the research that was presented, while also aiming to ensure that the collection is accessible to a genuinely interdisciplinary readership. While music examples are used in some of the chapters, these are kept to a minimum, and are supported by audio samples available at www.alc.manchester. ac.uk/subjects/music/research/projects/musicalcreativity.
This essay grows from a concern with the old art-historical problem of how the perception of art, or in this case more specifically architecture, changes over time. It sets out to explore how verbal representations preserve clues about such changes in the way we see the world, while proposing that the dialogue between subject and object is perhaps more palpable in texts than it is in pictures. The protagonist is seventeenth-century diarist John Evelyn, who travelled in Italy between 1644 and 1646. The account of this journey forms part of his seminal Diary, which he compiled mainly retrospectively from the 1660s onwards. One of the main seventeenth-century English sources for historians of all fields and by some even regarded as having changed travel writing, Evelyn is nevertheless well known for having copied generous parts of his text from earlier guidebooks.2 In the following I will try to dismantle sentence by sentence one short passage in which he describes the city of Genoa. Comparing his text to other seventeenth-century guidebooks allows us to see not only what Evelyn copied, but also what he altered, what he added, and, more importantly, what these alterations and additions tell us about contemporary modes of perception and representation. The ensuing analysis raises questions about concepts of creativity and originality in the period while probing the ordering of vision and knowledge in the seventeenth century.
Creation: a making or forming of something, as it were, out of nothing Edward Phillips, The New World of Words
Edward Phillips's attempt to define creation in 1671 highlights a number of issues that are central to developments in thinking about creativity, knowledge and artistic innovation during the seventeenth century. His idea of creating ‘something’ from ‘nothing’ implies, at one level, absolute novelty: a lack of precedence, a complete rupture with and effacement of a past state or experience; something appears where once there was emptiness or blankness. Simultaneously, however, the emphasis on ‘making’ and especially ‘forming’ suggests that there are materials to be moulded: existing matter to be reshaped into something new; Phillips suggests that creation has to be made from something, even as this ‘some-thing’ is described as ‘no-thing’. This ambivalence – the ‘as it were’ in the definition – hints at the multiple concepts and interpretations of creativity that existed in the seventeenth century.
In the early modern period – particularly in the realm of epistemology – creation was understood both in terms of reshaping, translating and reconfiguring that which exists and as the production of fresh entities ‘out of nothing’. Seventeenth-century theories of creativity seem to emanate from precisely this tension between novelty and precedent, between the purity of the new and the foundation of the old.