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Over the past 20 years, a large body of research has documented a relationship between higher nurse-to-patient staffing ratios and better patient outcomes, including shorter hospital stays, lower rates of failure to prevent mortality after an in-hospital complication, inpatient mortality for multiple types of patients, hospital-acquired pneumonia, unplanned extubation, respiratory failure and cardiac arrest.1–5 In addition, patients report higher satisfaction when they are cared for buy viagra without a prescription in hospitals with higher staffing levels.6 7To date, most studies have not identified an ‘optimal’ nurse staffing ratio,8 which creates a challenge for determining appropriate staffing levels. If increasing nurse staffing always produces at least some improvement in the quality of care, how does one determine what staffing level is best?. This decision is ultimately an economic one, balancing the benefits of nurse staffing with the other options for which those resources buy viagra without a prescription could be used. It is in this context that hospitals develop staffing plans, generally based on historical patterns of patient acuity.Practical challenges of nurse staffingHospital staffing plans provide the structure necessary for determining hiring and scheduling, but fall short for a number of reasons. First, there buy viagra without a prescription are multiple ways in which patient acuity can be measured, which can have measurable effects on the staffing levels resulting from acuity models.9 Second, patient volume and acuity can shift rapidly with changes in the volume of admissions, discharges and transfers between units.

Third, staffing plans provide little guidance regarding the optimal mix of permanent staff, variable staff and externally contracted staff.The paper by Saville and colleagues10 in this issue of BMJ Quality &. Safety addresses the latter two issues by buy viagra without a prescription applying a simulation model to identify the optimal target for baseline nurse staffing in order to minimise periods of understaffing. Included in this model is consideration of the extent to which hospitals should leverage temporary personnel (typically obtained through an external agency) to fill gaps. The model acknowledges the likelihood that a hospital cannot realistically prevent all shifts from buy viagra without a prescription having a shortfall of nurses at all times, as well as the reality that hospital managers lack information about the best balance between permanent and temporary staff. In addition, the analysis includes a calculation of the costs of each staffing approach, drawing from the records of 81 inpatient wards in four hospital organisations.The application of sophisticated simulation models and other advanced analyticl approaches to analysis of nurse staffing has been limited to date, and this paper is an exemplar of the value of such research.

Recent studies have used machine learning methods to forecast hospital discharge volume,11 a discrete event simulation model to determine nursing staff needs in a neonatal intensive care unit,12 and a prediction model using machine learning and hierarchical linear regression to link variation in nurse staffing with patient outcomes.13 This new study applied a unique Monte Carlo simulation model to estimate demand for nursing care and test different strategies to meet demand.The results of the analysis are not surprising in that hospitals are much less buy viagra without a prescription likely to experience understaffed patient shifts if they aim to have higher baseline staffing. The data demonstrate a notable leftward skew, indicating that hospitals are more likely to have large unanticipated increases in patient volume and acuity than to have unanticipated decreases. This results in hospitals being more likely to have shifts that are understaffed than shifts that are overstaffed, which inevitably places pressure on hospitals to staff at a higher level and/or have access to a larger pool of temporary nurses buy viagra without a prescription. It also is not surprising that hospitals will need to spend more money per patient day if they aim to reduce the percent of shifts that are understaffed. What is surprising about the results is that hospitals do not necessarily achieve cost savings by relying on temporary personnel versus setting regular staffing at a higher level.Trade-offs between permanent and temporary staffThe temporary nursing workforce enables healthcare facilities to maintain flexible yet full care teams based on patient care needs.

Hospitals can use temporary nurses to address staffing gaps during leaves of absence, turnover or gaps between recruitment of permanent nurses, as well buy viagra without a prescription as during high-census periods. Temporary personnel are typically more expensive on an hourly basis than permanent staff. In addition, over-reliance on buy viagra without a prescription temporary staff can have detrimental effects on permanent nurses’ morale and motivation. Orientations prior to shifts are often limited, which leads to a twofold concern as temporary nurses feel ill-prepared for shifts and permanent staff feel flustered when required to bring the temporary nurse up to speed while being expected to continue normal operations.14 Agency nurses may be assigned to patients and units that are incongruent with their experience and skills—either to unfamiliar units, which affects their ability to confidently deliver care, or to less complex patients where they feel as if their skills are not used adequately.14 15 These issues can create tension between temporary and permanent nursing staff, which can be compounded by the wage disparity. Permanent staff might feel demoralised and expendable when working alongside temporary staff who are not integrated into the social fabric of the buy viagra without a prescription staff.16Hospital managers also must be cognisant of the potential quality impact of relying heavily on temporary nursing staff.

Research on the impact of contingent nursing employment on costs and quality have often found negative effects on quality, including mortality, and higher costs.17 18 However, other studies have found that the association between temporary nursing staff and low quality result from general shortages of nursing staff, which make a hospital more likely to employ temporary staff, and not directly from the contingent staff.19–21 Thus, temporary nurses play an important role in alleviating staffing shortages that would otherwise lead to lower quality of care.22Charting a path forward in hospital management and healthcare researchThe maturation of electronic health records and expansion of computerised healthcare management systems provide opportunities both for improved decision making about workforce deployment and for advanced workforce research. In the area of workforce management, nursing and other leaders buy viagra without a prescription have a growing array of workforce planning tools available to them. Such tools are most effective when they display clear information about predicted patient needs and staff availability, but managers still must rely on their on-the-ground understanding of their staff and their context of patient care.23 Integration of human resources data with patient outcomes data has revealed that individual nurses and their characteristics have important discrete effects on the quality of care.24 25 Future development of workforce planning tools should translate this evidence to practice. In addition, new technology platforms buy viagra without a prescription are emerging to facilitate direct matching between temporary healthcare personnel and healthcare organisations. One recent study tested a smartphone-based application that allowed for direct matching of locum tenens physicians with a hospital in the English National Health Service, finding that the platform generated benefits including greater transparency and lower cost.26 Similar technologies for registered nurses could facilitate better matching between hospital needs and temporary nurses’ preparedness to meet those needs.Analytical methods that fully leverage the large datasets compiled through electronic health records, human resources systems and other sources can be applied to advance research on the composition of nursing teams to improve quality of care.

As noted above, prior research has applied machine learning and discrete event simulation to analyses of buy viagra without a prescription healthcare staffing. Other recent studies have leveraged natural language processing of nursing notes to identify fall risk factors27 and applied data mining of human resources records to understand the job titles held by nurses.28 Linking these rapidly advancing analytical approaches that assess the outcomes and costs of nurse staffing strategies, such as the work by Saville and colleagues published in this issue, to data on the impact of nurse staffing on the long-term costs of patient care will further advance the capacity of hospital leaders to design cost-effective policies for workforce deployment.Guidelines aim to align clinical care with best practice. However, simply publishing a guideline rarely triggers behavioural changes to match guideline recommendations.1–3 We thus transform guideline recommendations into actionable tasks by introducing interventions that promote behavioural changes meant to produce guideline-concordant care. Unfortunately, not much has changed in the 25 buy viagra without a prescription years since Oxman and colleagues concluded that we have no ‘magic bullets’ when it comes to changing clinician behaviour.4 In fact, far from magic bullets, interventions aimed at increasing the degree to which patients receive care recommended in guidelines (eg, educational interventions, reminders, audit and feedback, financial incentives, computerised decision support) typically produce disappointingly small improvements in care.5–10Much improvement work aims to ‘make the right thing to do the easy thing to do.’ Yet, design solutions which hardwire the desired actions remain few and far between. Further, improvement interventions which ‘softwire’ such actions—not guaranteeing that they occur, but at least increasing the likelihood that clinicians will deliver the care recommended in guidelines—mostly produce small improvements.5–9 Until this situation changes, we need to acknowledge the persistent reality that guidelines themselves represent a main strategy for promoting care consistent with current evidence, which means their design should promote the desired actions.11 12In this respect, guidelines constitute a type of clinical decision support.

And, like all decision support interventions, guidelines buy viagra without a prescription require. (1) user testing to assess if the content is understood as intended and (2) empirical testing to assess if the decision support provided by the guideline does in fact promote the desired behaviours. While the processes for developing guidelines have received substantial attention over the years,13–18 surprisingly little attention buy viagra without a prescription has been paid to empirically answering basic questions about the finished product. Do users understand guidelines as intended?. And, what version of a buy viagra without a prescription given guideline engenders the desired behaviours by clinicians?.

In this issue of BMJ Quality and Safety, Jones et al19 address this gap by using simulation to compare the frequency of medication errors when clinicians administer an intravenous medication using an existing guideline in the UK’s National Health Service (NHS) versus a revised and user-tested version of the guideline that more clearly promotes the desired actions. Their findings buy viagra without a prescription demonstrate that changes to guideline design (through addition of actionable decision supports) based on user feedback does in fact trigger changes in behaviour that can improve safety. This is an exciting use of simulation, which we believe should encourage further studies in this vein.Ensuring end users understand and use guidelines as intendedJones and colleagues’ approach affords an opportunity to reflect on the benefits of user testing and simulation of guidelines. The design and evaluation of their revised guidelines provides an excellent example of a careful stepwise progression in the development and evaluation of buy viagra without a prescription a guideline as a type of decision support for clinicians. First, in a prior study,20 they user tested the original NHS guidelines to improve retrieval and comprehension of information.

The authors produced a revised guideline, which included reformatted sections as well as increased support for key calculations, such as for infusion rates. The authors again user tested the revised buy viagra without a prescription guideline, successfully showing higher rates of comprehension. Note that user testing refers to a specific approach focused on comprehension rather than behaviour21 and is distinct from usability testing. Second, in the current study, Jones et al evaluated whether buy viagra without a prescription nurse and midwife end users exhibited the desired behavioural changes when given the revised guidelines (with addition of actionable decision supports), compared with a control group working with the current version of the guidelines used in practice. As a result, Jones and colleagues verify that end users (1) understand the content in the guideline and (2) actually change their behaviour in response to using it.Simulation can play a particularly useful role in this context, as it can help identify problems with users’ comprehension of the guideline and also empirically assess what behavioural changes occur in response to design changes in the guidelines.

The level of methodological control and qualitative detail that simulation provides is difficult to feasibly replicate with buy viagra without a prescription real-world pilot studies, and therefore simulation fills a critical gap.Jones et al report successful changes in behaviour due to the revised guidelines in which they added actionable decision supports. For example, their earlier user testing found that participants using the initial guidelines did not account for displacement volume when reconstituting the powdered drug, leading to dosing errors. A second error with the initial guidelines involved participants using the shortest infusion rate provided (eg, guidelines state ‘1 to 3 hours’), without realising that the shortest rate is not appropriate for certain doses (eg, 1 hour is buy viagra without a prescription appropriate for smaller doses, but larger doses should not be infused over 1 hour because the drug would then be administered faster than the maximum allowable infusion rate of 3 mg/kg/hour). These two issues were addressed in the revised guidelines by providing key determinants for ‘action’ such as calculation formulas that account for displacement volume and infusion duration, thereby more carefully guiding end users to avoid these dose and rate errors. These changes to the guideline triggered specific behaviours (eg, calculations that account for all variables) buy viagra without a prescription that did not occur with the initial guidelines.

Therefore, the simulation testing demonstrated the value of providing determinants for action, such as specific calculation formulas to support end users, by showing a clear reduction in dose and rate errors when using the revised guidelines compared with the initial guidelines.The authors also report that other types of medication-specific errors remained unaffected by the revised guidelines (eg, incorrect technique and flush errors)—the changes made did not facilitate the desired actions. The initial guidelines indicate buy viagra without a prescription ‘DO NOT SHAKE’ in capital letters, and there is a section specific to ‘Flushing’. In contrast, the revised guidelines do not capitalise the warning about shaking the vial, but embed the warning with a numbered sequence in the medication preparation section, aiming to increase the likelihood of reading it at the appropriate time. The revised guidelines do not have a section specific to flushing, but embed the flushing instructions as an unnumbered step in the administration section. Thus, the value of embedding technique and flushing information within the context of use was not validated in the simulation testing (ie, no significant differences in the rates of these errors), highlighting precisely the pivotal role buy viagra without a prescription that simulation can play in assessing whether attempts to improve usability result in actual behavioural changes.Finally, simulation can identify potential unintended consequences of a guideline.

For instance, Jones and colleagues observed an increase in errors (although not statistically significant) that were not medication specific (eg, non-aseptic technique such as hand washing, swabbing vials with an alcohol wipe). Given that the revised guidelines were specific to the medication tested, it is unusual that we see a tendency toward buy viagra without a prescription a worsening effect on generic medication preparation skills. Again, this finding was not significant, but we highlight this to remind ourselves of the very real possibility that some interventions might introduce new and unexpected errors in response to changing workflow and practice6. Simulations offer an opportunity buy viagra without a prescription to spot these risks in advance.Now that Jones et al have seen how the revised guidelines change behaviour, they are optimally positioned to move forward. On one hand, they have the option of revising the guidelines further in attempts to address these resistant errors, and on the other, they can consider designing other interventions to be implemented in parallel with their user-tested guidance.

At first glance, the errors that were resistant to change appear to be mechanical tasks that end users might think of as applying uniformly to multiple medications buy viagra without a prescription (eg, flush errors, non-aseptic technique). Therefore, a second intervention that has a more general scope (rather than drug specific) might be pursued. Regardless of what buy viagra without a prescription they decide to pursue, we applaud their measured approach and highlight that the key takeaway is that their next steps are supported with clearer evidence of what to expect when the guidelines are released—certainly a helpful piece of information to guide decisions as to whether broad implementation of guidelines is justified.Caveats and conclusionSimulation is not a panacea—it is not able to assess longitudinal adherence, and there are limitations to how realistically clinicians behave when observed for a few sample procedures when under the scrutiny of observers. Further, studies where interventions are implemented to assess whether they move the needle on the outcomes we care about (eg, adverse events, length of stay, patient mortality) are needed and should continue. However, having end users physically perform clinical tasks with the intervention in representative environments represents an important buy viagra without a prescription strategy to assess the degree to which guidelines and other decision support interventions in fact promote the desired behaviours and to spot problems in advance of implementation.

Such simulation testing is not currently a routine step in intervention design. We hope it becomes a more common phenomenon, with more improvement work following the example of the approach so effectively demonstrated by Jones and colleagues..

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Among systems operating in both 2016 and 2018 years, the median number of physicians increased by 29 percent, from 285 to 369. This has implications for cost, access, and quality of care.Although most research on health systems suggests that consolidation is associated with higher prices, a new article published in Health Services Research suggests that vertically integrated health systems might provide greater value under payment models that provide incentives to improve value. In this study, the buy viagra without a prescription authors found lower costs and similar quality scores from system hospitals compared with non-system hospitals that were participating in Medicare’s Comprehensive Care for Joint Replacement, a mandatory episode payment model.These studies were conducted by researchers at Mathematica, which leads AHRQ’s Coordinating Center for Comparative Health System Performance. This initiative seeks to understand the factors that affect health systems’ use of patient-centered outcomes research in delivering care. Learn more about the Comparative Health System Performance Initiative..

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Associate Professor Sylvia Gustin, The University of NSW, Neuroscience Research Australia – received $2.5 million for her research project on using female viagra amazon virtual reality training to restore touch sensation. Professor Jane Butler – Neuroscience Research Australia, The University of NSW, received $1.5 million to develop a treatment to restore voluntary function after spinal cord injury. And Dr Euan McCaughey, Neuroscience Research Australia, The University of NSW, received $2.4 million for his research into using muscle stimulation to improve respiratory function for people with tetraplegia.

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Our new Spinal Cord Injury Research Centre and these research projects will dramatically improve Australia’s understanding of how to best treat people with these life-long injuries,” Professor Schofield said. €œNeuRA thanks the NSW Government for funding the Spinal Cord Injury Research Grants Program, and SpinalCure Australia for its tireless efforts in campaigning for more research funding to improve the quality of life for people with a spinal cord injury.” Information on grant recipients and their research projects is available on the OHMR Funded Research Directory​​.​​​.

A strict permit system is in place for all flights arriving in NSW from Victoria and passengers undergo comprehensive buy viagra without a prescription police Where to buy cheap amoxil and health checks upon arrival. Health Minister Brad Hazzard said all flights are met by NSW Health staff and police officers to ensure anyone entering NSW complies with the current health orders. “There are only limited reasons anyone from Victoria should be entering NSW and people have been turned back despite being allowed on the plane in Melbourne,” Mr buy viagra without a prescription Hazzard said.

€œVictorian residents are not permitted into NSW at all unless they are needed for specific purposes and even then have to apply for and get a permit. €œWe are constantly reviewing the situation in Victoria and will adjust the health orders as necessary to protect the people of NSW.” Anyone who flies into NSW from Victoria must either be a NSW resident or have buy viagra without a prescription a relevant permit that allows entry into NSW – that can include:defence officialsdoctors and nursescritical workers in energy, mining and constructionchild protection workersdisability workers.All travellers are provided with a pack of two masks and hand sanitiser by the airlines. Upon arrival into NSW all passengers from Victoria are.

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Recommended they be collected in a private car by family or friendsnot to use public transport to get hometo only sit in the back seat of a car with the windows open and air conditioning not on recirculationtold to wear their buy viagra without a prescription face masks and observe hand hygiene recommendations, andcalled to make sure they arrive home.NSW Health is provided the contact details of everyone who enters NSW from Victoria. NSW Police is conducting regular compliance checks for people told to go into ‘Home Isolation’ as well as responding to reports from the community in relation to suspected breaches. Over the weekend, NSW Police visited almost 600 homes to check that those that were meant to be self-isolating buy viagra without a prescription were doing so.

In addition to that, over the same period NSW Police received 374 calls to Crime Stoppers reporting suspected breaches of the health orders, the majority of which were for people suspected of not following self-isolation rules. ​Seven cutting-edge NSW research projects have been awarded almost $15 million in NSW Government grants to improve the health of people with spinal cord injuries (SCI).Treasurer Dominic Perrottet and Minister for Health and Medical Research Brad Hazzard today announced the grants at the opening of the Neuroscience Research Australia (NeuRA) Spinal Cord Injury Research Centre at Randwick where three of the projects will be carried out. €œThe investment of close to $15 million over four years was a centrepiece of our last Budget and it’s exciting to see the range of research buy viagra without a prescription projects now underway,” Mr Perrottet said.

€œThis is about improving the health and wellbeing of people with spinal cord injuries, and these projects could help people not just in NSW but right around the world.” Minister Hazzard said every one of the innovative projects holds tremendous promise to improve treatment for people living with spinal cord injuries, giving back muscle function, sense of touch and other abilities that most of us take for granted. €œA spinal injury brings very substantial life challenges, but advances in research now mean survivors can have a better quality of life – and even buy viagra without a prescription the hope of a cure,” Mr Hazzard said. €œThese projects have great scope, from investigating ways to restore touch sensation through immersive virtual reality through to using electrical stimulation to improve breathing for people affected by the most severe form of paralysis.” The following grant recipients will conduct their research at the new NeuRA centre.

Associate Professor Sylvia Gustin, The University of NSW, buy viagra without a prescription Neuroscience Research Australia – received $2.5 million for her research project on using virtual reality training to restore touch sensation. Professor Jane Butler – Neuroscience Research Australia, The University of NSW, received $1.5 million to develop a treatment to restore voluntary function after spinal cord injury. And Dr Euan McCaughey, Neuroscience Research Australia, The University of NSW, received $2.4 million for his research into using muscle stimulation to improve respiratory function for people with tetraplegia.

The projects have been awarded through the NSW Government’s Spinal Cord Injury Research Grants program, launched in November 2019, with guidance from an advisory committee buy viagra without a prescription of spinal cord injury experts. NeuRA CEO, Professor Peter Schofield, said the range and scope of the funded research projects held exciting promise for health related outcomes. €œNeuroscience Research Australia is buy viagra without a prescription at the forefront of spinal cord injury research in Australia.

Our new Spinal Cord Injury Research Centre and these research projects will dramatically improve Australia’s understanding of how to best treat people with these life-long injuries,” Professor Schofield said. €œNeuRA thanks the NSW Government for funding the Spinal Cord Injury Research Grants Program, and SpinalCure Australia for its tireless efforts in campaigning for more research funding to improve the quality of life for people with a spinal cord injury.” Information on grant recipients and their research projects is available on the OHMR Funded Research Directory​​.​​​.