RESUMO
Annual patient attendances at a pre-operative assessment department increased by 24.8% from 5659 in 2009, to 7062 in 2012. The unit was staffed by administrative staff, nurses, and health care assistants (HCA). Medical review was accessed via on call medical staff, or notes were sent to anaesthetists for further review. With rising demand, patient waits increased. The average lead time for a patient (time from entering the department to leaving) was 79 minutes. 9.3% of patients attended within two weeks of their scheduled surgery date. 10% of patients were asked to return on a later day, as there was not sufficient capacity to undertake their assessment. There were nine routes of referral in to the department. Patients moved between different clinic rooms and the waiting area several times. Work patterns were uneven, as many attendances were from out-patient clinics which meant peak attendance times were linked to clinic times. There were substantial differences in the approaches of different nurses, making the HCA role difficult. Patients reported dissatisfaction with waits. Using a Lean quality improvement process with rapid PDSA cycles, the service changed to one in which patients were placed in a room, and remained there for the duration of their assessment. Standard work was developed for HCWs and nurses. Rooms were standardised using 5S processes, and set up improved to reduce time spent looking for supplies. A co-ordinator role was introduced using existing staff to monitor flow and to organise the required medical assessments and ECGs. Timing of booked appointments were altered to take account of clinic times. Routes in to the department were reduced from nine to one. Ten months after the work began, the average lead time had reduced to 59 minutes. The proportion of people attending within two weeks of their surgery decreased from 9.3% to 5.3%. Referrals for an anaesthetic opinion decreased from 30% to 20%, and in the month reviewed no one had to return to be seen as a result of limited capacity.
RESUMO
For the past decade, considerable research has been conducted at a series of small lakes receiving treated liquid effluent containing elevated selenium (Se) from the Key Lake uranium (U) milling operation in northern Saskatchewan, Canada. Several studies related to this site, including field collections of water, sediment, and biota (biofilm and/or periphyton, invertebrates, fish, and birds), semicontrolled mesocosm and in situ caging studies, and controlled laboratory experiments have recently been published. The aim of the present investigation was to compile the site-specific information obtained from this multidisciplinary research into an integrative perspective regarding the influence of Se speciation on biogeochemical cycling and food web transfer of Se in coldwater ecosystems. Within lakes, approximately 50% of sediment Se was in the form of elemental Se, although this ranged from 0% to 81% among samples. This spatial variation in elemental Se was positively correlated with finer particles (less sand) and percent total organic C content in sediments. Other Se species detected in sediments included selenosulfides, selenite, and inorganic metal selenides. In contrast, the major Se form in sediment-associated biofilm and/or periphyton was an organoselenium species modeled as selenomethionine (SeMet), illustrating the critical importance of this matrix in biotransformation of inorganic Se to organoselenium compounds and subsequent trophic transfer to benthic invertebrates at the base of the food web. Detritus displayed a Se speciation profile intermediate between sediment and biofilm, with both elemental Se and SeMet present. In benthic detritivore (chironomid) larvae and emergent adults, and in foraging and predatory fishes, SeMet was the dominant Se species. The proportion of total Se present as a SeMet-like species displayed a direct nonlinear relationship with increasing whole-body Se in invertebrates and fishes, plateauing at approximately 70% to 80% of total Se as a SeMet-like species. In fish collected from reference lakes, a selenocystine-like species was the major Se species detected. Similar Se speciation profiles were observed using 21-day mesocosm and in situ caging studies with native small-bodied fishes, illustrating the efficient bioaccumulation of Se and use of these semicontrolled approaches for future research. A simplified conceptual model illustrating changes in Se speciation through abiotic and biotic components of lakes was developed, which is likely applicable to a wide range of northern industrial sites receiving elevated Se loading into aquatic ecosystems.
