Readmission Risk Assessment Technologies and the Anchoring and Adjustment Heuristic.

Approximately 23% of patients discharged from primary healthcare facilities are readmitted within 30 days at an annual cost of roughly $42 billion. To remedy this problem, healthcare providers are attempting to deploy readmission risk estimation tools, but how they might be used in the traditional, human-expert-centered decision process is not well understood. One such tool estimates readmission risk based on 50 patient-specific factors. This paper reports on a study performed in collaboration with Order of St. Francis Healthcare to determine how healthcare workers' own risk estimates are influenced by the tool, specifically testing the hypothesis that they will first anchor towards tool results while making adjustments based on their expertise, and then make further adjustments when additional human expert opinions are presented. Task analysis was performed, fictional patient scenarios were developed, and a survey of 56 subjects in two stratified groups of case managers was conducted. Data from the control and experiment groups were analyzed using ANOVA/GLM and t-tests. Results indicate that the healthcare workers' risk estimates were influenced by the anchor provided by the tool, then adjusted based on their expertise. The workers further adjusted their estimates in response to new expert human inputs. Thus, a reliance on both the predictive model and human expertise was observed.

Pediatric and neonatal extracorporeal life support technology component utilization: are US clinicians implementing new technology?

The objective of this investigation is to describe recent changes made in extracorporeal life support (ECLS) technology in the US Postal survey to directors and coordinators of all 125 US ECLS centers identified by Extracorporeal Life Support Organization as of November 2010, with follow-up of nonrespondents. Spearman coefficients were used to correlate the method of updating knowledge of ECLS technology with the likelihood of changing technology, and to correlate decision-making hierarchy with the likelihood of changing equipment. The response rate was 75% representing 34 states, and the majority of respondents were ECLS coordinators (56.6%). Respiratory diagnosis is the predominant indication for ECLS at any age. Over 40% of centers are using a hollow-fiber oxygenator for neonates and 80% of pediatric patients. Roller pumps are used in 70% of neonatal and pediatric ECLS. Forty-two percent of centers changed the oxygenator type within the past 3 years, while 30% changed both the oxygenator and pump. Less than 10% of centers reported problems with either oxygenator or pump in both neonates and pediatric ECLS. Forty-six percent of respondents that changed oxygenators cited that the primary reason for changing was "clinical preference/experience," while the other half was split between "FDA approval" and "Research results." In 40% of centers, a multidisciplinary group made decisions on changing technology. This survey indicates that over one-half of ECLS centers implemented new technology within the past 3 years. Knowledge of ECLS technology and safe operation of ECLS circuit components is essential in preventing some of the mechanical complications.

Neonatal extracorporeal life support: will the newest technology reduce morbidity?

The objectives of this review are to describe the Extracorporeal Life Support (ECLS) research at the Penn State Pediatric Cardiovascular Research evaluating new pediatric ECLS components and to discuss a proposed continuous quality improvement model after implementation of new technology. Review of current literature pertaining to studies at the Penn State Hershey Children's Hospital (PSHCH) is presented along with a retrospective chart review of ECLS pediatric patients from January 2000 to June 2010. We describe improvements in the newest hollow-fiber oxygenator demonstrating a lower pressure drop (compared with silicone), and in the newest RotaFlow centrifugal pump which allows higher hemodynamic energy delivered to the patient at higher flow rates with less retrograde flow. The miniaturized pediatric circuit implemented is portable and primes quickly for rapid deployment. Our model of continuous quality improvement includes in-depth evaluation of all circuit component performance through on-site in vivo and in vitro testing at the PSHCH. We utilize the same model to provide comprehensive education and hands-on training of the staff. This cycle can be repeated for evaluation and implementation of any new circuit component. Our comprehensive approach to ECLS may provide the ideal means from which to safely introduce new technology.

Pediatric extracorporeal life support systems: education and training at Penn State Hershey Children's Hospital.

The following is a description of the training offered to extracorporeal life support (ECLS)-trained staff at the Penn State Hershey Children's Hospital. Changes with the ECLS circuit prompted the need for an initiative to train staff in the care of patients requiring ECLS support. In addition to didactic material, we incorporated a "hands-on" approach in designing the education. During the didactic portion, the circuit was demonstrated as a wet lab. The final step offered a voluntary visit to the animal research facility utilizing clinical case scenarios which allowed participants to articulate and demonstrate proper circuit management.The effort throughout this process was to build a competent ECLS team which will ultimately provide our patients with the greatest chance for a full recovery.

Concomitant adsorption and desorption of organic vapor in dry and humid air streams using microwave and direct electrothermal swing adsorption.

Industrial gas streams can contain highly variable organic vapor concentrations that need to be processed before they are emitted to the atmosphere. Fluctuations in organic vapor concentrations make it more difficult to operate a biofilter when compared to a constant vapor concentration. Hence, there is a need to stabilize the concentration of rapidly fluctuating gas streams for optimum operation of biofilters. This paper describes new concomitant adsorption desorption (CAD) systems used with variable organic vapor concentration gas streams to provide the same gas stream, but at a user-selected constant vapor concentration that can then be more readily processed by a secondary air pollution control device such as a biofilter. The systems adsorb organic vapor from gas streams and simultaneously heat the adsorbent using microwave or direct electrothermal energy to desorb the organic vapor at a user-selected set-point concentration. Both systems depicted a high degree of concentration stabilization with a mean relative deviation between set-point and stabilized concentration of 0.3-0.4%. The direct electrothermal CAD system was also evaluated to treat a humid gas stream (relative humidity = 85%) that contained a variable organic vapor concentration. The high humidity did not interfere with CAD operation as water vapor did not adsorb but penetrated through the adsorbent These results are important because they demonstrate the ability of CAD to effectively dampen concentration fluctuation in gas streams.

Steady-state and dynamic desorption of organic vapor from activated carbon with electrothermal swing adsorption.

A new method to achieve steady-state and dynamic-tracking desorption of organic compounds from activated carbon was developed and tested with a bench-scale system. Activated carbon fiber cloth (ACFC) was used to adsorb methyl ethyl ketone (MEK) from air streams. Direct electrothermal heating was then used to desorb the vapor to generate select vapor concentrations at 500 ppmv and 5000 ppmv in air. Dynamic-tracking desorption was also achieved with carefully controlled yet variable vapor concentrations between 250 ppmv and 5000 ppmv, while also allowing the flow rate of the carrier gas to change by 100%. These results were also compared to conditions when recovering MEK as a liquid, and using microwaves as the source of energy to regenerate the adsorbent to provide MEK as a vapor or a liquid.

Constrained optimization for green engineering decision-making.

Green engineering requires the designer to consider a very extensive set of environmental impacts. To minimize these impacts, the designer must significantly expand his or her "toolset" of product design concepts, alternative materials, manufacturing systems, and analytic methods for addressing life cycle impacts. This can overwhelm a designer, who then resorts to overly simplistic rules or checklists out of necessity. The central issue is how to identify all "pollution prevention pays" opportunities and then how to deal with the unavoidable tradeoffs that arise after all these opportunities have been exhausted. This paper presents a framework for employing mathematical decision modeling toward this end. A domain-independent constrained optimization formulation is presented. A multiattribute utility function reflects the willingness to pay for environmental improvement and is the basis of the objective function. The feasibility constraints reflect the unavoidable tradeoffs. Several case studies are presented, including power systems, floor tile manufacturing, and computer systems.