Views and experiences of using integrated care pathways (ICPs) for caring for people in the last days to hours of life: results from a cross-sectional survey of UK professionals.

OBJECTIVES: To determine the views and experiences of health and social care professionals on using integrated care pathways (ICPs)for caring for people in the last days to hours of life. METHODS: Online cross-sectional questionnaire survey of UK professionals working in UK primary and secondary care settings. RESULTS: 1331 professionals returned completed questionnaires. Ninety-three per cent (1138/1228) of respondents used the Liverpool Care Pathway (LCP) or local variant. Eighty-eight (1089/1234) felt ICPs enabled professionals to provide better care for individuals and their families/carers. ICPs were viewed as promoting patient-centred holistic care, improving pain and symptom control, providing guidance and standards and improving communication with patients/families. Sixty-two per cent (770/1234) had no concerns regarding the use of ICPs. Areas of concern included incorrect use and implementation of the ICP, poor communication with families, junior level staff making decisions and insufficient education and support. CONCLUSIONS: There was strong support for using ICPs for caring for people in the last days to hours of life. ICPs were viewed as supporting high-quality patient-centred holistic care. Given the recommendations of the More Care Less Pathway report, those that develop the guidance and support that replace the LCP need to incorporate the aspects of this that have resulted in the benefits seen by professionals within this survey, but also learn from the instances where ICPs have failed to prevent poor care, or worse, have contributed to it.

Supercritical fluid extraction of mercury species.

Supercritical fluid extraction was used to recover organic and inorganic mercury species. Variations in pressure, water, methanol, and chelator create methods that allowed separation of inorganic from organic mercury species. When extracted using a compromised set of extraction conditions, the order of extraction was methyl, phenyl and inorganic mercury. For the individually optimized conditions, quantitative recoveries were observed. Level as low as 20 ppb were extracted and then determined using ICP.

Effects of engine speed and accessory load on idling emissions from heavy-duty diesel truck engines.

A nontrivial portion of heavy-duty vehicle emissions of NOx and particulate matter (PM) occurs during idling. Regulators and the environmental community are interested in curtailing truck idling emissions, but current emissions models do not characterize them accurately, and little quantitative data exist to evaluate the relative effectiveness of various policies. The objectives of this study were to quantify the effect of accessory loading and engine speed on idling emissions from a properly functioning, modern, heavy-duty diesel truck and to compare these results with data from earlier model year vehicles. It was found that emissions during idling varied greatly as a function of engine model year, engine speed, and accessory load conditions. For the 1999 model year Class 8 truck tested, raising the engine speed from 600 to 1050 rpm and turning on the air conditioning resulted in a 2.5-fold increase in NOx emissions in grams per hour, a 2-fold increase in CO2 emissions, and a 5-fold increase in CO emissions while idling. On a grams per gallon fuel basis, NOx emissions while idling were approximately twice as high as those at 55 mph. The CO2 emissions at the two conditions were closer. The NOx emissions from the 1999 truck while idling with air conditioning running were slightly more than those of two 1990 model year trucks under equivalent conditions, and the hydrocarbon (HC) and CO emissions were significantly lower. It was found that the NOx emissions used in the California Air Resources Board's (CARB) EMFAC2000 and the U.S. Environmental Protection Agency's (EPA) MOBILE5b emissions inventory models were lower than those measured in all of the idling conditions tested on the 1999 truck.

On-road facility to measure and characterize emissions from heavy-duty diesel vehicles.

In response to lingering concerns about the utility of dynamometer data for mobile source emissions modeling, the U.S. Environmental Protection Agency (EPA) has constructed an on-road test facility to characterize the real-world emissions of heavy-duty trucks. The facility was designed to effectively demonstrate the full range of vehicle operation and to measure the emissions produced. Since it began operation, the facility has been continuously upgraded to incorporate state-of-the-art technology. Its potential uses include collecting modal emissions data, validating dynamometer test parameters and results, and demonstrating new emission control technologies.

Specific extraction of chromium(VI) using supercritical fluid extraction.

In some situations, it is no longer sufficient to give a total concentration of a metal. Instead, what is required to understand the potential toxicity of a sample is the concentration of metal species or oxidation state. When developing species specific methods, the major concern is that the integrity of the species ratio is not changed. In other words, the sample preparation or the analytical method will not convert metal ions from one oxidation state to another. Normal extraction techniques and chromatography methods have shown some tendencies to change species ratios. An ideal extraction method would extract the metal efficiently while retaining the metal's oxidation state. The properties of supercritical fluids should approach the ideal of retention of oxidation states. For example, the need for speciation of chromium is obvious since Cr(III) is considered an essential element while Cr(VI) is thought to be toxic and carcinogenic. This paper presents the results of a species specific extraction of Cr(VI) using two different carbamate derivatives as the chelator. Supercritical fluid extraction (SFE) coupled with a fluorinated dithiocarbamate and a methanol modifier allows extraction of 1 ppm Cr(VI) from a solid matrix with a recovery level of 88.4+/-2.57% using the NIST standard sample. The optimized conditions using the HP 7680 supercritical fluid extractor were: 0.1 ml of methanol, 0.05 ml of pure water, and 0.01 g of chelate via a saturation chamber.

Determination of ATP using chelation-enhanced fluorescence.

A method for the direct determination of ATP that exhibits reasonable sensitivity, and responds to very few interferants, has been developed. The chelation-enhanced fluorescence between N-(anthracen-9'-yl methyl)tris(3-aminopropyl) amine and adenosine 5'-triphosphate is utilized in this determination. The method was tested in batch and flow-injection analysis (FIA) modes. The typical detection limit for FIA determination of ATP is 1 muM, with a linear range of 0.5-100 ppm. A typical relative standard deviation at 20 ppm is 2.3%.