18 research outputs found
Association of Staphylococcus aureus Bacterial Load and Colonization Sites With the Risk of Postoperative S. aureus Infection.
No full textBACKGROUND: The independent effects of extranasal-only carriage, carriage at multiple bodily sites, or the bacterial load of colonizing Staphylococcus aureus (SA) on the risk of developing SA surgical site infections and postoperative bloodstream infections (SA SSI/BSIs) are unclear. We aimed to quantify these effects in this large prospective cohort study. METHODS: Surgical patients aged 18 years or older were screened for SA carriage in the nose, throat, or perineum within 30 days before surgery. SA carriers and noncarriers were enrolled in a prospective cohort study in a 2:1 ratio. Weighted multivariable Cox proportional hazard models were used to assess the independent associations between different measures of SA carriage and occurrence of SA SSI/BSI within 90 days after surgery. RESULTS: We enrolled 5004 patients in the study cohort; 3369 (67.3%) were SA carriers. 100 SA SSI/BSI events occurred during follow-up, and 86 (86%) of these events occurred in SA carriers. The number of colonized bodily sites (adjusted hazard ratio [aHR], 3.5-8.5) and an increasing SA bacterial load in the nose (aHR, 1.8-3.4) were associated with increased SA SSI/BSI risk. However, extranasal-only carriage was not independently associated with SA SSI/BSI (aHR, 1.5; 95% CI, 0.9-2.5). CONCLUSIONS: Nasal SA carriage was associated with an increased risk of SA SSI/BSI and accounted for the majority of SA infections. Higher bacterial load, as well as SA colonization at multiple bodily sites, further increased this risk
Postoperative Staphylococcus aureus Infections in Patients With and Without Preoperative Colonization
No full textIMPORTANCE: Staphylococcus aureus surgical site infections (SSIs) and bloodstream infections (BSIs) are important complications of surgical procedures for which prevention remains suboptimal. Contemporary data on the incidence of and etiologic factors for these infections are needed to support the development of improved preventive strategies. OBJECTIVES: To assess the occurrence of postoperative S aureus SSIs and BSIs and quantify its association with patient-related and contextual factors. DESIGN, SETTING, AND PARTICIPANTS: This multicenter cohort study assessed surgical patients at 33 hospitals in 10 European countries who were recruited between December 16, 2016, and September 30, 2019 (follow-up through December 30, 2019). Enrolled patients were actively followed up for up to 90 days after surgery to assess the occurrence of S aureus SSIs and BSIs. Data analysis was performed between November 20, 2020, and April 21, 2022. All patients were 18 years or older and had undergone 11 different types of surgical procedures. They were screened for S aureus colonization in the nose, throat, and perineum within 30 days before surgery (source population). Both S aureus carriers and noncarriers were subsequently enrolled in a 2:1 ratio. EXPOSURE: Preoperative S aureus colonization. MAIN OUTCOMES AND MEASURES: The main outcome was cumulative incidence of S aureus SSIs and BSIs estimated for the source population, using weighted incidence calculation. The independent association of candidate variables was estimated using multivariable Cox proportional hazards regression models. RESULTS: In total, 5004 patients (median [IQR] age, 66 [56-72] years; 2510 [50.2%] female) were enrolled in the study cohort; 3369 (67.3%) were S aureus carriers. One hundred patients developed S aureus SSIs or BSIs within 90 days after surgery. The weighted cumulative incidence of S aureus SSIs or BSIs was 2.55% (95% CI, 2.05%-3.12%) for carriers and 0.52% (95% CI, 0.22%-0.91%) for noncarriers. Preoperative S aureus colonization (adjusted hazard ratio [AHR], 4.38; 95% CI, 2.19-8.76), having nonremovable implants (AHR, 2.00; 95% CI, 1.15-3.49), undergoing mastectomy (AHR, 5.13; 95% CI, 1.87-14.08) or neurosurgery (AHR, 2.47; 95% CI, 1.09-5.61) (compared with orthopedic surgery), and body mass index (AHR, 1.05; 95% CI, 1.01-1.08 per unit increase) were independently associated with S aureus SSIs and BSIs. CONCLUSIONS AND RELEVANCE: In this cohort study of surgical patients, S aureus carriage was associated with an increased risk of developing S aureus SSIs and BSIs. Both modifiable and nonmodifiable etiologic factors were associated with this risk and should be addressed in those at increased S aureus SSI and BSI risk
Postoperative Staphylococcus aureus infections in patients with and without preoperative colonization
No full textAbstract: Importance Staphylococcus aureus surgical site infections (SSIs) and bloodstream infections (BSIs) are important complications of surgical procedures for which prevention remains suboptimal. Contemporary data on the incidence of and etiologic factors for these infections are needed to support the development of improved preventive strategies. Objectives To assess the occurrence of postoperative S aureus SSIs and BSIs and quantify its association with patient-related and contextual factors. Design, Setting, and Participants This multicenter cohort study assessed surgical patients at 33 hospitals in 10 European countries who were recruited between December 16, 2016, and September 30, 2019 (follow-up through December 30, 2019). Enrolled patients were actively followed up for up to 90 days after surgery to assess the occurrence of S aureus SSIs and BSIs. Data analysis was performed between November 20, 2020, and April 21, 2022. All patients were 18 years or older and had undergone 11 different types of surgical procedures. They were screened for S aureus colonization in the nose, throat, and perineum within 30 days before surgery (source population). Both S aureus carriers and noncarriers were subsequently enrolled in a 2:1 ratio. Exposure Preoperative S aureus colonization. Main Outcomes and Measures The main outcome was cumulative incidence of S aureus SSIs and BSIs estimated for the source population, using weighted incidence calculation. The independent association of candidate variables was estimated using multivariable Cox proportional hazards regression models. Results In total, 5004 patients (median [IQR] age, 66 [56-72] years; 2510 [50.2%] female) were enrolled in the study cohort; 3369 (67.3%) were S aureus carriers. One hundred patients developed S aureus SSIs or BSIs within 90 days after surgery. The weighted cumulative incidence of S aureus SSIs or BSIs was 2.55% (95% CI, 2.05%-3.12%) for carriers and 0.52% (95% CI, 0.22%-0.91%) for noncarriers. Preoperative S aureus colonization (adjusted hazard ratio [AHR], 4.38; 95% CI, 2.19-8.76), having nonremovable implants (AHR, 2.00; 95% CI, 1.15-3.49), undergoing mastectomy (AHR, 5.13; 95% CI, 1.87-14.08) or neurosurgery (AHR, 2.47; 95% CI, 1.09-5.61) (compared with orthopedic surgery), and body mass index (AHR, 1.05; 95% CI, 1.01-1.08 per unit increase) were independently associated with S aureus SSIs and BSIs. Conclusions and Relevance In this cohort study of surgical patients, S aureus carriage was associated with an increased risk of developing S aureus SSIs and BSIs. Both modifiable and nonmodifiable etiologic factors were associated with this risk and should be addressed in those at increased S aureus SSI and BSI ris
Postoperative Staphylococcus aureus infections in patients with and without preoperative colonization
No full textQuestionWhat is the cumulative incidence of Staphylococcus aureus surgical site infections (SSIs) and bloodstream infections (BSIs) in Europe, and what factors are associated with an increased risk of SSIs and BSIs?FindingsIn a cohort study of 5004 surgical patients, the weighted cumulative incidence of S aureus SSIs and BSIs was 1.23%. Preoperative S aureus carriage, mastectomy or neurosurgery, higher body mass index, and having nonremovable implants in the body were independently associated with S aureus SSIs and BSIs.MeaningStaphylococcus aureus SSIs and BSIs are important postoperative complications, and future interventions aimed at prevention of these infections should focus on at-risk surgical patient groups to achieve a higher efficacy
Postoperative Staphylococcus aureus Infections in Patients With and Without Preoperative Colonization
No full textImportance Staphylococcus aureus surgical site infections (SSIs) and bloodstream infections (BSIs) are important complications of surgical procedures for which prevention remains suboptimal. Contemporary data on the incidence of and etiologic factors for these infections are needed to support the development of improved preventive strategies.Objectives To assess the occurrence of postoperative S aureus SSIs and BSIs and quantify its association with patient-related and contextual factors.Design, Setting, and Participants This multicenter cohort study assessed surgical patients at 33 hospitals in 10 European countries who were recruited between December 16, 2016, and September 30, 2019 (follow-up through December 30, 2019). Enrolled patients were actively followed up for up to 90 days after surgery to assess the occurrence of S aureus SSIs and BSIs. Data analysis was performed between November 20, 2020, and April 21, 2022. All patients were 18 years or older and had undergone 11 different types of surgical procedures. They were screened for S aureus colonization in the nose, throat, and perineum within 30 days before surgery (source population). Both S aureus carriers and noncarriers were subsequently enrolled in a 2:1 ratio.Exposure Preoperative S aureus colonization.Main Outcomes and Measures The main outcome was cumulative incidence of S aureus SSIs and BSIs estimated for the source population, using weighted incidence calculation. The independent association of candidate variables was estimated using multivariable Cox proportional hazards regression models.Results In total, 5004 patients (median [IQR] age, 66 [56-72] years; 2510 [50.2%] female) were enrolled in the study cohort; 3369 (67.3%) were S aureus carriers. One hundred patients developed S aureus SSIs or BSIs within 90 days after surgery. The weighted cumulative incidence of S aureus SSIs or BSIs was 2.55% (95% CI, 2.05%-3.12%) for carriers and 0.52% (95% CI, 0.22%-0.91%) for noncarriers. Preoperative S aureus colonization (adjusted hazard ratio [AHR], 4.38; 95% CI, 2.19-8.76), having nonremovable implants (AHR, 2.00; 95% CI, 1.15-3.49), undergoing mastectomy (AHR, 5.13; 95% CI, 1.87-14.08) or neurosurgery (AHR, 2.47; 95% CI, 1.09-5.61) (compared with orthopedic surgery), and body mass index (AHR, 1.05; 95% CI, 1.01-1.08 per unit increase) were independently associated with S aureus SSIs and BSIs.Conclusions and Relevance In this cohort study of surgical patients, S aureus carriage was associated with an increased risk of developing S aureus SSIs and BSIs. Both modifiable and nonmodifiable etiologic factors were associated with this risk and should be addressed in those at increased S aureus SSI and BSI risk
South African travel writing and bias
No full textIncludes bibliographical references (leaves 92-96).This thesis spotlights the travel and leisure magazine industry within South Africa. It contends that the travel writing genre is susceptible to a number of biases, both past and present, which ultimately affect the way its overall content is produced and presented to the public. This work was substantiated through a set of qualitative interviews with key professionals within the South African travel and leisure magazine industry, as well as through a theme- based content analysis of a number of local travel writing publications. This study adds to a rather extensive line of research written on the topic of travel writing regarding a number of older criticisms of bias including 'othering', escapism, and gendering. However, it also focuses on a number of more modem biases such as direct advertising, advertorial usage, as well as the acceptance of 'freebies' and barter agreements, none of which has been given much attention in previous research. The sheer existence of these and other biases within the modem South African travel and leisure magazine industry exhibits an absolute necessity of examination into such a topic, especially given the importance and overall influence that the travel writing industry has on a country's economic standing and overall image
Impact of education for sustainability at a Montessori primary school: From silos to systems thinking
No full textThis research investigated Education for Sustainability (EfS) at an independent Montessori primary school, located in the Perth metropolitan area of Western Australia. A longitudinal case study involving analysis of data from a twenty year period was conducted to determine the effectiveness of EfS. Historical information about EfS at the school from 1990 to 2005 was examined, with the main focus of the study being on the impact of the Australian Sustainable Schools Initiative (AuSSI) between 2005 and 2009. AuSSI promotes a whole school, whole systems thinking approach to EfS.
Three school-based issues in EfS were studied. Firstly, the research aimed to determine what elements of EfS were in operation in the school prior to involvement in AuSSI. Secondly, student outcomes including engagement with whole systems thinking, attitudes and values, knowledge and understandings, and skills and behaviours related to EfS, were investigated during the first five years of participation in AuSSI. Thirdly, teacher perceptions of the EfS program, including engagement with whole systems thinking, were examined during this same time period.
A case study approach was employed to enable in-depth investigation of EfS in the life of the school prior to, during and post implementation of AuSSI. This approach facilitated revelation of participants' lived experiences, their perceptions and understandings of EfS, as well as detailed information about student outcomes in EfS. Case study methodology was also compatible with the culture and processes of the participating school and provided an opportunity for utilising a whole systems thinking approach. Data was gathered from a range of sources, through surveys, interviews, observation and document analysis over a five year period. The total participants included eleven teachers and seventy five students.
The research identified particular antecedents of EfS in the Montessori Method of education that existed in the school prior to AuSSI, including the whole child approach, together with the Montessori learning environment, curriculum and values. Following participation in AuSSI, student attitudes and values, knowledge and understandings, and skills and behaviours related to EfS were enhanced for all year levels. However, after three years when specific EfS actions and projects ceased, student EfS outcomes were limited. Furthermore, students’ thinking and behaviour indicated a ‘silo’, rather than whole systems thinking approach to EfS. Teachers perceived the EfS program as highly effective in the initial three years after joining AuSSI. Key elements that enhanced EfS included EfS staff champions who had access to EfS networks, leadership support, and active school community involvement in all EfS processes. However, after three years of being an AuSSI school, the culmination of reduced leadership support for EfS, lack of staff training, vague designation of staff with EfS responsibilities and inadequate community involvement, resulted in cessation of the EfS program. Teacher perceptions on whole systems thinking revealed alignment between Montessori philosophy, EfS and whole system thinking was more in theory than in practice.
Through an in-depth longitudinal case study of a school this research highlighted the importance of whole school EfS professional learning, embedding EfS and whole systems thinking across the curriculum at all year levels, whole school support, and the usefulness of a sustainability continuum that recognizes the complex, dynamic interplay of issues involved in a school’s EfS journey. It is strongly recommended improvements to pre-service teacher education in EfS are implemented, and a review of the AuSSI toolkit is conducted to refine EfS evaluation processes and to target the specific EfS needs of teachers at different stages of schooling, as well as to enhance understanding and implementation of the whole systems thinking approach. Finally, EfS professional learning for all school staff in all schools is warranted to enhance depth of EfS engagement
Li yong lin chuang shen he ji hua jia qiang Xianggang de lin chuang guan zhi
No full textPh.D.Clinical audits aim at creating a sustainable quality improvement process, and that is achieved by continuous systematic patient outcome data tracking with consistent follow-up criteria. Previous clinical audit studies focused mainly on its application in intervention effectiveness measurement and analysis of hospital service quality. The compliance on risk preventive model formulation could also be found in some studies. Recent researches on quality improvement largely relied on data collected by the National Surgical Quality Improvement Program (ACS-NSQIP) of the American College of Surgeons. This United States-based clinical record platform that is highly acknowledged on improving patient outcome at the affiliated hospitals. Alongside the rising trend of utilising clinical audit projects in clinical governance enhancement, there is a growing importance of optimising audit programme design, application, and customisation. However, whether it is beneficial to conduct a regional-wide or a department-focused clinical audit in terms of improving surgical outcome quality is unknown. In this thesis, we examine the use of regional and departmental audit programmes – Surgical Outcomes Monitoring and Improvement Programme (SOMIP) and Post-operative Complication Monitoring Programme (PPCMP). Studying these the local programmes would reinforce our knowledge on the benefit of clinical audit programme implementation in Hong Kong. We utilise clinical audit to investigate clinical intervention efficiency and administrative phenomenon in Hong Kong. We also establish locally relevant recommendation on launching an in-house clinical audit programme.Methods and results1) Tackling surgical site infections with specific care bundle in elective hepatobiliary and pancreatic surgeryPost-operative surgical site infection (SSI) is associated with a prolonged hospital stay, and increased post-operative morbidity and mortality. A team-specific SSI care bundle was designed and implemented in the Hepato-biliary and Pancreatic (HBP) surgical team at the Department of Surgery of PWH in 2009. The bundle serves the purpose to reduce SSI in elective surgery. We evaluated the efficiency of SSI care bundle with the SOMIP clinical audit data.1,319 cases were captured in the 6 years period and there were 139 (10.5%) SSI incidence observed. Pre- and post-intervention analysis was performed with the χ² test, it suggested that surgical site infection (SSI) rate significantly dropped (21.7% vs. 8.7%, OR=0.346, 95% C.I.=0.190–0.629; p<0.001). No significant difference on SSI in the subsequent years could be observed and the rates of SSI had maintained between 7.3% and 9.3% The data confirmed a positive impact of SSI care bundle on the reduction of post-operative SSI, and such positive impact remained sustainable in subsequent years when the care bundle is applied in long-term. (Further described in Chapter III)2) The “weekend effect” in emergency general and specialty surgeryIt is believed the weekend service quality may be relatively inferior as a result of the lack of senior surgeons, less available facilities and longer waiting time. The observation of a higher mortality rate among patients admitted over the weekend compared to the weekday is known as the “weekend effect”. The effect would be different according to operative magnitudes, surgical types and the size of surgical units. This study aimed to close our knowledge gap on the presence of “weekend effect” in emergency surgery services from 2010 to 2014 at the PWH Department of Surgery. Individual analysis was conducted respectively for general surgery and specialty surgery.1,860 patients underwent emergent surgeries in the 4-year study period. 1,398 (75.2%) patients’ operations were performed on the weekdays. The overall post-operative 30-day mortality was 115 (6.2%) and 654 (35.2%) for morbidity. We then found there is a significant different between weekday and weekend mortality (p=0.033). Multivariant analysis was performed and suggested the day of operation (weekday/ weekend) was an independent variable for post-operative mortality. We found that weekends had lower mortality than the weekdays (OR=0.538, 95% C.I.=0.315–0.919; p=0.023). Analysis was further separated into general and specialty surgeries. There was a significant difference between weekday and weekend mortality in general surgery. Day of week was an independent variable for mortality and weekends had lower mortality than the weekdays (OR=0.516, 95% C.I.=0.298–0.893; p=0.018). No significant difference could be observed between weekends and weekdays for morbidity in general surgeries, and morbidity and mortality in specialty surgeries. These results suggested emergency surgery services in the Department of Surgery of PWH were not affected by the “weekend effect” (i.e. mortality increases after operations conducted over the weekends). (Further described in Chapter IV)3) Exploring the effect of hospital volume on outcome of elective major hepatectomy in Hong KongSurgical techniques require years of training and practice and it is considered a crucial determinant in surgical outcomes. It is believed that a higher volume hospital provides more practice experience to surgeons than the lower volume hospitals, thus better surgical service is expected. Currently, it is an unknown in the relationship between hospital-volume and surgical outcome in Hong Kong. We focused on studying the volume-outcome relationship of elective major hepatectomy because the operation is technically demanding and variation of hospital-volume in different departments. Hospital volume categories (high-volume hospital and low-volume hospital – HVH and LVH) were defined by the volume threshold that shows a significant difference in post-operative 30-day mortality. The primary endpoints were 30-day morbidity, intra-operative blood loss, and length of in-hospital stay. We also investigated if service networking provided by the HVHs to LVHs would be beneficial to the surgical performance of the LVHs.Over the 7-year study period (June 2009 – July 2016), 2,389 patients were captured by the SOMIP and the overall post-operative 30-day mortality rate was 2.1% (51 patients). A total of 81 annual hospital-volume entries was included and the median annual hospital-volume of elective major hepatectomy was 18 (range from 1 to 170). The relationship between hospital-volume and 30-day mortality was plotted by scattered-plot and tested with χ² test, and the cutoff volume was 40 major hepatectomy cases per year (OR=2.23, 95% C.I.=1.25–3.98; p=0.005). By using this cut-off volume, high-volume hospitals had consistent mortality rates below 4%. We observed a significant difference in 30-day morbidity rate (p<0.001) and length of hospital stay (p=0.027) but no significant difference for intra-operative blood loss between the high-volume and low-volume hospitals. This means receiving elective major hepatectomy from the HVHs would give better surgical outcomes (morbidity and length of stay) than the LVHs. In addition to this, we also found there was a significant difference on the annual 30- day mortality in the service networking supported LVHs to the LVHs without this support (0% vs. 34.5%; p=0.049). (Further elaborated in Chapter V)4) Predicting risk of post-operative pneumonia after elective operations with Post-operative Pneumonia Risk Indication Score in Elective Surgery (PRISES)Post-operative pneumonia (POP) is one of the major morbidities causing an increased length of in-hospital stay and higher operative mortality. Developing a POP risk score with the risk factors for POP is beneficial to healthcare providers with easier high-risk group identification. There were some POP risk scores developed in different places but the accuracy for application in Hong Kong is questionable. This study utilised the local clinical audit data to develop an institutional POP risk score for elective surgeries – PRISES. This risk calculator was formulated and verified with different sets of internal clinical audit programme data for POP prediction accuracy.The retrospective cohort study included 5,433 elective patients aged from 18 to 100 years. 22 risk factors referenced from the SOMIP analysis were tested using multivariate logistic regression in our study. There were 10 variables found significantly related to POP and included in the PRISES (gender, American Society of Anaesthesiologist (ASA), surgical teams, pulse in surgery, surgical magnitude, operating time, steroid use, functional health dependency, presence of dyspnoea, and potassium range). The Hosmer-Lemeshow test showed that this model fit the samples (p=0.878) and the Area Under the curve of the Receiver Operating Characteristic (AUROC) showed a good fit (p=0.819, 95% C.I.= 0.782–0.856). PRISES consists of 5 cut-off points for the likelihood of POP development. PRISES was verified with another set of cohort data and the model fit (Hosmer-Lemeshow test, p=0.360, AUROC p=0.901, 95% C.I.=0.852–0.950). These results suggested individual patient could use PRISES to predict the probability of developing POP after elective operations. (Further elaborated in Chapter VI)5) Improving surgical quality in a surgical department with close to real-time monitoring system – the Post-procedure Complication Monitoring Programme (PPCMP)The surgeon-led PPCMP keeps track of the patients’ post-operative outcomes. This inhouse surgical audit programme was officially launched in 2010, aimed at cultivating higher accountability of surgeons to the operative outcomes and better quality of surgeries. The platform enables prompt responses from surgeons and department management to unanticipated events and regular service quality assurance. This study describes the setup of the PPCMP and the improvement of operative outcomes after introducing the programme to the Department of Surgery at the PWH.PCMP captured 39,104 patients in total and 43,273 procedure records were conducted during the 7-year-period (2010 – 2016). The 30-day morbidity and 30-day mortality decreased significantly after the first year of PPCMP implementation in 2010 (OR=0.626, p<0.001; OR=0.750, p=0.05), and plateaued in subsequent years. Decreased 30-day morbidity and mortality could be observed in all surgical teams, surgical types and surgical magnitudes. These results suggested the introduction of PPCMP could contribute to the improvement of surgical quality through ongoing patient outcome monitoring mechanisms and educational-based reviewing component. (Further described in Chapter VII)6) Accuracy of Post-procedure Complication Monitoring Programme (PPCMP) on capturing surgical outcomeRecord accuracy in clinical audit project is crucial for judgment making and broadening of its applications. Following the previous study on PPCMP setup and implementation, this study validates the accuracy of PPCMP surgical outcome records by comparing with the SOMIP standard. The hypotheses the accuracy on operative outcome archive of the PPCMP was high. This would strengthen the creditability of adopting the PPCMP audit data for various quality improvement strategies. Record concordance was defined by if the presence or absence of post-operative complication on the particular patient, was listed the same in both PPCMP and SOMIP systems. We conducted logistic regression analysis for the trend of record concordance on post-operative 30-day mortality and morbidity. We also study the characteristics of the discrepant records.A total of 9,416 patients was captured in the SOMIP (reference records) programme in the 4-year study period, and PPCMP captured 9,410 (99.9%) of them. The overall concordance rate of post-operative morbidity was 84.0% and 99.7% for 30-day mortality. In-depth studies found the discrepancy dropped from 2010 to 2011 for both morbidity (p<0.01) and mortality (p<0.05) records, and showed no significant difference in the subsequent years (2011–2014). Sub-group analysis was performed on the accuracy of capturing 30-day morbidity record characteristics. Discrepant records in morbidity were significantly higher in patients of the Colorectal surgery (OR=1.197, p<0.05) and significantly lower in Paediatric Surgery and Paediatric Urology (OR=0.579, p<0.001). In surgical types, the 30-day morbidity discrepant rate in elective operations is lower than emergency operations (OR=0.601, p<0.001). In surgical magnitude, major operations matched better with the SOMIP gold standard than the ultra-major operations (OR=0.710, p<0.001). As the overall discrepancy was low, we conclude that PPCMP recorded patient outcomes in a precise and up-to-standard manner, and is fit to be utilised for future retrospective studies. (Further elaborated in Chapter VIII)ConclusionClinical audit data has proven to be useful in multiple aspects that include retrospective studies, formulate risk prevention model and monitoring the quality of surgical care. We explored with a series of studies using clinical audit. Our results suggested a customised SSI care bundle was an effective tool to lower surgical site infection in elective HBP surgery. Followed by that, our findings discovered service quality of emergent surgeries performed over the weekends is no different from the weekdays. By using clinical audit data, we also found HA hospitals that have a higher volume of elective major hepatectomy is associated with lower 30-day post-operative morbidity and shorter length of hospital stay. This represented an effective use of clinical audit data on health services planning in different hospitals within the same public healthcare system. Then we explored the use of audit programme data to formulate a POP risk model for elective surgery (PRISES). The risk score demonstrated a good POP prediction fit in our setting. Next, we studied on the surgical outcome audit programme that is instituted in our department – PPCMP. Our researches suggested that even with the support of a regional clinical audit project – SOMIP, introducing an in-house audit programme offers multiple benefits. PPCMP supplemented with a direct enhancement of clinical service improvement climate in a surgical department, it enabled prompt responses to adverse clinical phenomena. We concluded that audit programmes, such as PPCMP and SOMIP, facilitate long-term monitoring of surgical quality. Continuous commitment in carrying out clinical audit programmes offers sustainable and efficient surgical quality assurance; strengthen clinical governance in Hong Kong.臨床審核是英國國民保健署(NHS) 管治臨床工作的關鍵部分之一。它是透過分析系統、團隊或組織的表現，將提供優質的住院管理服務。現時臨床審核被多地的醫療機關視為提高醫療質量的重要工具，它的應用亦日趨增加。在香港，香港醫院管理局(醫管局)於2008 起引進了《于衛成效監察計劃》 (SOMIP) ，通過提供年度臨床審核分析數據及質量改進建議，支持並提升公立醫院的外科服務質寰。次年，沙田威爾斯親王醫院(PWH) 的中文大學醫學外科部亦成立了該部門的臨床審核一《手術後併發症監測計劃》 (PPCMP) 。目標以更便於前線外科醫護人員的臨床審核小組加強外部門臨床管治。由於臨床審核所帶動的效益並不顯注，所以不少醫療服務提供者忽視了臨床審核的重要性。這種尚未有清晰了解的互動關係成為了一個研究領域。因此這論文將香港臨床審核進行全面研究，並為在香港實施有系統的臨床審核計劃提供應用和效益層面的參考作用。本論文將對現存於香港的兩個臨床審核計劃- SOMIP 及PPCMP，進行研究。研究分開為三個主體。第一，研究臨床審核所收集的數據，並對預防併發痕針對性工具進行強率分析，同時亦了解並發症和死亡率的出現模式。第三，使用臨床審核計劃數據制定手術後出現併發症的風險評分血統。第三亦是在最後，對香港中文大學外科部的臨床審核一PPCMP 進行深入研究，展示了這個個別部門外科屬隊採用的部門式的臨床審核計劃當中所以應用的結構、工作編制和接勤安排。同時亦針對審核計劃引進以後所帶動的于術表現數據變化進行了解。然後，亦針對研究這個部門式的臨床審核計劃在記銬子術數據的準確性。這將加強PWH 外科臨床審核計劃反映準確數據的可信度，並為其他機構設實臨床審核計劃提供參考基準。本論文總結了臨床審核計劃對外科手術成效及質量改進的重要性。臨床審核計劃需要透過跨團樺的協同努力來維持及實蹺，它將提供多樣化的改進工具以確保香港在外科護理標準方面能夠發揮優質服務水平。Chan, Ho Man.Thesis Ph.D. Chinese University of Hong Kong 2019.Includes bibliographical references (leaves 157-173).Abstracts also in Chinese.Title from PDF title page (viewed on 18, May, 2021).Chan, Ho Man
The Design and Tests of a VLSI Matrix Printer Controller for a Teletype KSD Model 43
No full textThe report covers the design, implementation and test phases of an MOS Model 43 MAtrix Printer KSR terminal CONtroller (MACON). The circuit elements are P-channel enhancement mode MOS transistors, integrated in Monolithic form using a Teletype MOS process. The chip is A 40 pin DIP, and is classified as a VLSI. It serves as the central terminal and line control unit of the Model 43 Basic Key-board Send Receive set. It coordinates the activities of the Data Link, Operators Console (key-board) and Matrix Printer, which contains the character font. The on-chip logic is divided into two basic data paths which can operate independently of each other: The transmit (TD) and Receive (RD) data paths, which process information originating from the Operators Console and Data Link, respectively. The TD&RD processed data is eventually presented to the MAtrix Printer logic chip (MA.PL); however, TD data can be forwarded simultaneously to the Data Link. The VLSI MOS chip, under study, involved the following scientific disciplines: A. The marketing sector, which assessed a specific product in terms of its various features, cost, and manufacturing constraints (i.e., the model 43 terminal). B. R&D systems engineering sector which translated features into engineering specifications. C. R&D MOS logic design and topological layout team, of which the author is a member, converted the specifications into MOS logic and generated a final Application tape. D. Photolothographic translation of I/O tape into Mask Radicals. E. The Processing Sector which was involved with Wafer shaping, doping, etching, annealing. The real chip emerges from this organization. (See Appendix A and B). F. Testing and Parametric characterization. G. Dicing the wafer, bonding of I/O pads, and DIP insertion. H. Stress application by the Approving Lab sector. I. Manufacturing of the terminal . The result of the above contributions is a VLSI chip, that replaced a multitude of discrete SSI, MSI, and LSI packages, thus reducing dramatically the cost and the size of the KSD, and directly enhancing the reliability of the terminal in question. The Model 43 is presently one of the best selling peripherals manufactured by Teletype Corporation. As the technology evolves, the need for improvement becomes obvious. MACON and MAPL and the operator\u27s console logic can be integrated today on a single chip, using N-channel depletion loads and double polysilicon self-aligned gate technology
Assessment of a Device for Standardized Laparotomy Closure
No full textIntroduction Common complications after surgical procedures include surgical site infection, wound rupture and incisional hernia. Wound healing can be influenced by the technique for abdominal access and closure. A Suture-Length to Wound-Length (SL/WLr) ratio ≥ 4 is advised to achieve a high-quality wound closure. This thesis describes the background and clinical realities of abdominal wall related complications as well as the development process and results from the evaluation of a novel device for standardized laparotomy closure. The aim was to assess the device from a technical, clinical and a health economy perspective. Method SutureTOOL is a handheld single use suture applicator with the purpose of facilitating best practise for wound closure by applying a to SL/WLr ≥ 4. It was developed by the author and a MedTech team associated with Lund University and evaluated in experimental, clinical and health economy models. Study I: Ten surgeons performed incision closures on an elk fascia model comparing SutureTOOL to NDS concerning adherence to SL/WLr 4. This was achieved in 98% for SutureTOOL and 30% for NDS. Closure time was 30% shorter when using the SutureTOOL. Study II: Fifteen surgeons performed incision fascial closures comparing Suture TOOL to NDS in a human autopsy model. Adherence to SL/WLr of 4 was 95% for SutureTOOL and 69% for NDS. Closure time was 30% shorter when using the SutureTOOL. Study III: Twenty-five surgeons and ten nurses performed needle pull-throughs in an incisional lamb leather model comparing SutureTOOL and two different sizes of curved suture needles for needle pull-through time, medial traction and forceps force. SutureTOOL was faster and resulted in less forceps force. Study IV: Five colorectal surgeons performed laparotomy closures with SutureTOOL in a single arm study on 38 colorectal patients. The primary endpoint was adherence to SL/WLr of ≥4. Secondary endpoints included closure time and surgical site infections. All patients received a SL/WLr of at least 4. Mean closure time was 7.4 min and the shortest closure time was 2.2 min. One SSI was detected and no patient suffered from wound dehiscence. Study V: The aim of the study was to compare the economic and clinical outcomes of laparotomy closure for patients using manual needle-driver suturing compared to SutureTOOL from a healthcare perspective in Sweden, France, UK and US. A decision tree model was developed to implement the analysis. The SutureTOOL was found to be cost-effective, reducing costs between 22% and 40% across country contexts. Savings were associated with reduced post-operative complications and reductions in operating room time. Conclusion: Wound infection and incisional hernia are common complications to abdominal surgery. These complications can be reduced by adhering to a standardized high quality closure technique. However, even though guidelines exist, they have been difficult to implement in clinical practice. The thesis showed a high adherence to SL/WLr of 4 for SutureTOOL, performed with consistent quality and faster compared to needle-driver suturing. Suture-TOOL has the potential to reduce wound complications and would be a cost-effective intervention
