Operative transportation planning in consumer goods supply chains

Transportation management in today’s consumer goods industry can be characterized by a high proportion of outsourced transportation services. Due to rising freight costs consumer goods manufacturers are looking for opportunities to increase the efficiency of their transportation network. This study presents an operational transportation planning problem typical of the consumer goods industry focusing on a network of suppliers, production facilities and warehousing locations. It comprises an analysis of freight costs in a consumer goods transportation network based on the freight rate structures. In this analysis a number of opportunities for efficiency gains are identified and consolidated in an operative transportation planning problem which is then numerically investigated. Furthermore, an overview of processes and organizational structures in transportation management is given with special focus on the integration of existing commercial Transportation Management Systems (TMS).     

Patient admission planning using Approximate Dynamic Programming

Tactical planning in hospitals involves elective patient admission planning and the allocation of hospital resource capacities. We propose a method to develop a tactical resource allocation and patient admission plan that takes stochastic elements into consideration, thereby providing robust plans. Our method is developed in an Approximate Dynamic Programming (ADP) framework and copes with multiple resources, multiple time periods and multiple patient groups with uncertain treatment paths and an uncertain number of arrivals in each time period. As such, the method enables integrated decision making for a network of hospital departments and resources. Computational results indicate that the ADP approach provides an accurate approximation of the value functions, and that it is suitable for large problem instances at hospitals, in which the ADP approach performs significantly better than two other heuristic approaches. Our ADP algorithm is generic, as various cost functions and basis functions can be used in various hospital settings.     

城市建筑群三维空间布局评价与优化——以厦门岛滨海地带为例

随着城市化进程的快速推进,城市建设带来了土地资源紧张,使得越来越多的城市向着高层化、立体化、智能化方向发展;城市建筑群三维空间的最优布局是城市集约化发展的基础条件。针对现阶段的城市建筑群三维空间布局存在一些不足,构建城市建筑群三维空间布局的评估方法体系。以厦门岛滨海地带为研究区,基于多源、多空间分辨率遥感影像数据,从建筑景观、热环境和视觉效果3个角度评价厦门岛滨海地带三维空间格局的现状;并总结城市三维空间布局优化发展模式;从建筑景观、热环境和视觉效果这三个角度提出了厦门岛滨海地带城市建筑三维空间的布局优化建议。三维空间布局评价的结果表明:(1)从建筑景观角度,不同功能建筑群与容积率关系:商业区容积率最高,其次是商品房居住区,文教区占地面积广且建筑密度低,民房居住区的容积率是最低的但其建筑密度高;(2)从热环境角度,考虑温度因素,建筑群建筑密度过大、建筑层数过多都会造成温度较高;(3)从视觉效果角度,研究区具有宽广的视觉空间和宽阔海面,与以山体为背景的天际线形成了鲜明的对比。此外,提出优化低层建筑和合理布局中高层建筑的建筑容积率,设计建筑形态多样化和优化天际线前景、中景和背景的层次布局,...     

Variability in Costs across Hospital Wards. A Study of Chinese Hospitals

Introduction

Analysts estimating the costs or cost-effectiveness of health interventions requiring hospitalization often cut corners because they lack data and the costs of undertaking full step-down costing studies are high. They sometimes use the costs taken from a single hospital, sometimes use simple rules of thumb for allocating total hospital costs between general inpatient care and the outpatient department, and sometimes use the average cost of an inpatient bed-day instead of a ward-specific cost.

Purpose

In this paper we explore for the first time the extent and the causes of variation in ward-specific costs across hospitals, using data from China. We then use the resulting model to show how ward-specific costs for hospitals outside the data set could be estimated using information on the determinants identified in the paper.

Methodology

Ward-specific costs estimated using step-down costing methods from 41 hospitals in 12 provinces of China were used. We used seemingly unrelated regressions to identify the determinants of variability in the ratio of the costs of specific wards to that of the outpatient department, and explain how this can be used to generate ward-specific unit costs.

Findings

Ward-specific unit costs varied considerably across hospitals, ranging from 1 to 24 times the unit cost in the outpatient department — average unit costs are not a good proxy for costs at specialty wards in general. The most important sources of variability were the number of staff and the level of capacity utilization.

Practice Implications

More careful hospital costing studies are clearly needed. In the meantime, we have shown that in China it is possible to estimate ward-specific unit costs taking into account key determinants of variability in costs across wards. This might well be a better alternative than using simple rules of thumb or using estimates from a single study.     

A complex endeavour: an ethnographic study of the implementation of the Sepsis Six clinical care bundle

Background

Implementation of the ‘Sepsis Six’ clinical care bundle within an hour of recognition of sepsis is recommended as an approach to reduce mortality in patients with sepsis, but achieving reliable delivery of the bundle has proved challenging. There remains little understanding of the barriers to reliable implementation of bundle components. We examined frontline clinical practice in implementing the Sepsis Six.

Methods

We conducted an ethnographic study in six hospitals participating in the Scottish Patient Safety Programme Sepsis collaborative. We conducted around 300 h of non-participant observation in emergency departments, acute medical receiving units and medical and surgical wards. We interviewed a purposive sample of 43 members of hospital staff. Data were analysed using a constant comparative approach.

Results

Implementation strategies to promote reliable use of the Sepsis Six primarily focused on education, engaging and motivating staff, and providing prompts for behaviour, along with efforts to ensure that equipment required was readily available. Although these strategies were successful in raising staff awareness of sepsis and engagement with implementation, our study identified that completing the bundle within an hour was not straightforward. Our emergent theory suggested that rather than being an apparently simple sequence of six steps, the Sepsis Six actually involved a complex trajectory comprising multiple interdependent tasks that required prioritisation and scheduling, and which was prone to problems of coordination and operational failures. Interventions that involved allocating specific roles and responsibilities for completing the Sepsis Six in ways that reduced the need for coordination and task switching, and the use of process mapping to identify system failures along the trajectory, could help mitigate against some of these problems.

Conclusions

Implementation efforts that focus on individual behaviour change to improve uptake of the Sepsis Six should be supplemented by an understanding of the bundle as a complex trajectory of work in which improving reliability requires attention to coordination of workflow, as well as addressing the mundane problems of interruptions and operational failures that obstruct task completion.

     

Cost-Analysis of Seven Nosocomial Outbreaks in an Academic Hospital

Objectives

Nosocomial outbreaks, especially with (multi-)resistant microorganisms, are a major problem for health care institutions. They can cause morbidity and mortality for patients and controlling these costs substantial amounts of funds and resources. However, how much is unclear. This study sets out to provide a comparable overview of the costs of multiple outbreaks in a single academic hospital in the Netherlands.

Methods

Based on interviews with the involved staff, multiple databases and stored records from the Infection Prevention Division all actions undertaken, extra staff employment, use of resources, bed-occupancy rates, and other miscellaneous cost drivers during different outbreaks were scored and quantified into Euros. This led to total costs per outbreak and an estimated average cost per positive patient per outbreak day.

Results

Seven outbreaks that occurred between 2012 and 2014 in the hospital were evaluated. Total costs for the hospital ranged between €10,778 and €356,754. Costs per positive patient per outbreak day, ranged between €10 and €1,369 (95% CI: €49-€1,042), with a mean of €546 and a median of €519. Majority of the costs (50%) were made because of closed beds.

Conclusions

This analysis is the first to give a comparable overview of various outbreaks, caused by different microorganisms, in the same hospital and all analyzed with the same method. It shows a large variation within the average costs due to different factors (e.g. closure of wards, type of ward). All outbreaks however cost considerable amounts of efforts and money (up to €356,754), including missed revenue and control measures.     

Controlling nosocomial infection based on structure of hospital social networks

Nosocomial infection (i.e. infection in healthcare facilities) raises a serious public health problem, as implied by the existence of pathogens characteristic to healthcare facilities such as methicillin-resistant Staphylococcus aureus and hospital-mediated outbreaks of influenza and severe acute respiratory syndrome. For general communities, epidemic modeling based on social networks is being recognized as a useful tool. However, disease propagation may occur in a healthcare facility in a manner different from that in a urban community setting due to different network architecture. We simulate stochastic susceptible-infected-recovered dynamics on social networks, which are based on observations in a hospital in Tokyo, to explore effective containment strategies against nosocomial infection. The observed social networks in the hospital have hierarchical and modular structure in which dense substructure such as departments, wards, and rooms, are globally but only loosely connected, and do not reveal extremely right-skewed distributions of the number of contacts per individual. We show that healthcare workers, particularly medical doctors, are main vectors (i.e. transmitters) of diseases on these networks. Intervention methods that restrict interaction between medical doctors and their visits to different wards shrink the final epidemic size more than intervention methods that directly protect patients, such as isolating patients in single rooms. By the same token, vaccinating doctors with priority rather than patients or nurses is more effective. Finally, vaccinating individuals with large betweenness centrality (frequency of mediating connection between pairs of individuals along the shortest paths) is superior to vaccinating ones with large connectedness to others or randomly chosen individuals, which was suggested by previous model studies.     

Cost analysis of early discharge after hip fracture.

OBJECTIVE--To ascertain the economic impact of an early discharge scheme for hip fracture patients. DESIGN--Population based study comparing costs of care for patients who had "hospital at home" as an option for rehabilitation and those who had no early discharge service available in their area of residence. SETTING--District hospital orthopaedic and rehabilitation wards and community hospital at home scheme. PATIENTS--1104 consecutively admitted patients with fractured neck of femur. 24 patients from outside the district were excluded. MAIN OUTCOME MEASURES--Cost per patient episode and number of bed days spent in hospital. RESULTS--Patients with the hospital at home option spent significantly less time as inpatients (mean of 32.5 v 41.7 days; p < 0.001). Those patients who were discharged early spent a mean of 11.5 days under hospital at home care. The total direct cost to the health service was significantly less for those patients with access to early discharge than those with no early discharge option (4884 pounds v 5606 pounds; p = 0.048). CONCLUSIONS--About 40% of patients with fractured neck of femur are suitable for early discharge to a scheme such as hospital at home. The availability of such a scheme leads to lower direct costs of rehabilitative care despite higher readmission costs. These savings accrue largely from shorter stays in orthopaedic and geriatric wards.     

A Time Study of Physicians’ Work in a German University Eye Hospital to Estimate Unit Costs

Background

Technical efficiency of hospital services is debated since performance has been heterogeneous. Staff time represents the main resource in patient care and its inappropriate allocation has been identified as a key factor of inefficiency. The aim of this study was to analyse the utilisation of physicians’ work time stratified by staff groups, tasks and places of work. A further aim was to use these data to estimate resource use per unit of output.

Methods

A self-reporting work-sampling study was carried during 14-days at a University Eye Hospital. Staff costs of physicians per unit of output were calculated at the wards, the operating rooms and the outpatient unit.

Results

Forty per cent of total work time was spent in contact with the patient. Thirty per cent was spent with documentation tasks. Time spent with documentation tasks declined monotonically with increasing seniority of staff. Unit costs were 56 € per patient day at the wards, 77 € and 20 € per intervention at the operating rooms for inpatients and outpatients, respectively, and 33 € per contact at the outpatient unit. Substantial differences in resources directly dedicated to the patient were found between these locations.

Conclusion

The presented data provide unprecedented units costs in inpatient Ophthalmology. Future research should focus on analysing factors that influence differences in time allocation, such as types of patients, organisation of care processes and composition of staff.     

RFID analytics for hospital ward management

In this paper, we present an RFID-enabled platform for hospital ward management. Active RFID tags are attached to individuals and assets in the wards. Active RFID readers communicate with the tags continuously and automatically to keep track of the real-time information about the locations of the tagged objects. The data regarding the locations and other transmitted information are stored in the ward management system. This platform enables capabilities of real-time monitoring and tracking of individuals and assets, reporting of ward statistics, and providing intelligence and analytics for hospital ward management. All of these capabilities benefit hospital ward management by enhanced patient safety, increased operational efficiency and throughput, and mitigation of risk of infectious disease widespread. A prototype developed based on our proposed architecture of the platform was tested in a pilot study, which was conducted in two medical wards of the intensive care unit of one of the largest public general hospitals in Hong Kong. This pilot study demonstrates the feasibility of the implementation of this RFID-enabled platform for practical use in hospital wards. Furthermore, the data collected from the pilot study are used to provide data analytics for hospital ward management.     

Factors and Models Associated with the amount of Hospital Care Services as Demanded by Hospitalized Patients: A Systematic Review

Background

Hospitals are constantly being challenged to provide high-quality care despite ageing populations, diminishing resources, and budgetary restraints. While the costs of care depend on the patients'' needs, it is not clear which patient characteristics are associated with the demand for care and inherent costs. The aim of this study was to ascertain which patient-related characteristics or models can predict the need for medical and nursing care in general hospital settings.

Methods

We systematically searched MEDLINE, Embase, Business Source Premier and CINAHL. Pre-defined eligibility criteria were used to detect studies that explored patient characteristics and health status parameters associated to the use of hospital care services for hospitalized patients. Two reviewers independently assessed study relevance, quality with the STROBE instrument, and performed data analysis.

Results

From 2,168 potentially relevant articles, 17 met our eligibility criteria. These showed a large variety of factors associated with the use of hospital care services; models were found in only three studies. Age, gender, medical and nursing diagnoses, severity of illness, patient acuity, comorbidity, and complications were the characteristics found the most. Patient acuity and medical and nursing diagnoses were the most influencing characteristics. Models including medical or nursing diagnoses and patient acuity explain the variance in the use of hospital care services for at least 56.2%, and up to 78.7% when organizational factors were added.

Conclusions

A larger variety of factors were found to be associated with the use of hospital care services. Models that explain the extent to which hospital care services are used should contain patient characteristics, including patient acuity, medical or nursing diagnoses, and organizational and staffing characteristics, e.g., hospital size, organization of care, and the size and skill mix of staff. This would enable healthcare managers at different levels to evaluate hospital care services and organize or reorganize patient care.     

Absenteeism among hospital staff during an influenza epidemic: implications for immunoprophylaxis.

The 1980-81 epidemic of influenza A/Bangkok 79 was responsible for increased absenteeism (1.7 times the rate for the corresponding period of the subsequent nonepidemic year) among selected hospital staff in Winnipeg''s Health Sciences Centre. Retrospective study of employment records for 25 of the centre''s largest departments showed excess sick-leave costs of about $24 500 during the 2-week period of peak absenteeism that included the epidemic. Although the centre was sampling prospectively for the virus the first positive results became available too late for chemoprophylactic measures to have been effective. The greater increase in absenteeism among nursing staff caring for patients with chronic respiratory disease and nurses working on general medical or pediatric acute infection/isolation wards suggested that these groups be targeted for influenza vaccination in hospitals.     

Foraging in nature: Contrasting responses to resource heterogeneity at small‐ and large‐spatial scales

A key problem faced by foragers is how to forage when resources are distributed heterogeneously in space. This heterogeneity and associated trade‐offs may change with spatial scale. Furthermore, foragers may also have to optimize acquiring multiple resources. Such complexity of decision‐making while foraging is poorly understood. We studied the butterfly Ypthima huebneri to examine how foraging decisions of adults are influenced by spatial scale and multiple resources. We predicted that, at a small‐spatial scale, the time spent foraging in a patch should be proportional to resources in the patch, but at large‐spatial scales, due to limitations arising from large travel costs, this relationship should turn negative. We also predicted that both adult and larval resources should jointly affect foraging butterflies. To test these predictions, we laid eleven plots and sub‐divided them into patches. We mapped nectar and larval resources and measured butterfly behavior in these patches and plots. We found that adult foraging behavior showed contrasting relationships with adult resource density at small versus large‐spatial scales. At the smaller‐spatial scale, butterflies spent more time feeding in resource‐rich patches, whereas at the large‐scale, butterflies spent more time feeding in resource‐poor plots. Furthermore, both adult and larval resources appeared to affect foraging decisions, suggesting that individuals may optimize search costs for different resources. Overall, our findings suggest that the variation in foraging behavior seen in foragers might result from animals responding to complex ecological conditions, such as resource heterogeneity at multiple spatial scales and the challenges of tracking multiple resources.     

Contribution from geriatric medicine within acute medical wards.

In 1977 a scheme of attachment to acute medical wards of consultants in geriatric medicine and associated junior medical staff was instituted in a large Edinburgh teaching hospital. The effect on admissions of patients aged 65 and over was examined for comparable periods before and during this arrangement. Mean and median stays were reduced for both sexes but more noticeably for women. The mean stay for all women aged over 65 was reduced from 25 to 16 days and for women aged over 85 from 50 to 19 days. The proportion staying under two weeks was significantly increased in both sexes, and the proportion discharged home also increased, correspondingly fewer patients being transferred to convalescent wards. These changes were not accompanied by increased transfers to the geriatric department, and probably the skills and extra resources available to the geriatric service were the factors mainly responsible for the changes in performance.     

Economic impact of combined torrefaction and pelletization processes on forestry biomass supply

The cost of supplying wood biomass from forestry operations in remote areas has been an obstacle to expansion of forest‐based bioenergy in much of the western United States. Economies of scale in the production of liquid fuels from lignocellulosic biomass feedstocks favor large centralized biorefineries. Increasing transportation efficiency through torrefaction and pelletization at distributed satellite facilities may serve as a means to expand the utilization of forestry residuals in biofuel production. To investigate this potential, a mixed‐integer linear program was developed to optimize the feedstock supply chain design with and without distributed pretreatment. The model uses techno‐economic assessment of scale‐dependent biomass pretreatment processes from existing literature and multimodal biomass transportation cost evaluations derived from a spatially explicit network analysis as input. In addition, the sensitivity of the optimal system configuration was determined for variations of key input parameters including the production scale of pretreatment facilities, road and rail transportation costs, and feedstock procurement costs. Torrefaction and densification were found to reduce transportation costs by $0.84 per GJ and overall delivered costs by $0.24 per GJ, representing 14.5% and 5.2% cost reductions compared to feedstock collection without pretreatment. Significant uncertainties remain in terms of the costs associated with deploying torrefaction equipment at the scales modeled, but the level of potential cost savings suggests further analysis and development of these alternatives.     

Recycle in fermentation processes

Until recently, the recycle of the solid (microbial), liquid, or gaseous phases in microbiological processes has only been practiced rarely, with the notable exception of activated sludge processes for wastewater treatment, where recycling of a large fraction of the microbial phase is essential for process stability and performance. During the last decade, the economic impact of a number of politically motivated changes with respect to energy and feedstock costs and availability, and legislation directed towards markedly higher levels of environmental protection have encouraged the evaluation and subsequent development of recycle technology in the fermentation industry. Many of the developments have occurred in isolation and some have failed to result in either an improvement in process economics or any reduction in the quantity of pollutants discharged. This article seeks to review the present diversity of approaches to recycle technology in fermentation processes in order to provide a sensible basis for future developments.     

Multimorbidity combinations,costs of hospital care and potentially preventable emergency admissions in England: A cohort study

BackgroundPatients with multimorbidities have the greatest healthcare needs and generate the highest expenditure in the health system. There is an increasing focus on identifying specific disease combinations for addressing poor outcomes. Existing research has identified a small number of prevalent “clusters” in the general population, but the limited number examined might oversimplify the problem and these may not be the ones associated with important outcomes. Combinations with the highest (potentially preventable) secondary care costs may reveal priority targets for intervention or prevention. We aimed to examine the potential of defining multimorbidity clusters for impacting secondary care costs.Methods and findingsWe used national, Hospital Episode Statistics, data from all hospital admissions in England from 2017/2018 (cohort of over 8 million patients) and defined multimorbidity based on ICD-10 codes for 28 chronic conditions (we backfilled conditions from 2009/2010 to address potential undercoding). We identified the combinations of multimorbidity which contributed to the highest total current and previous 5-year costs of secondary care and costs of potentially preventable emergency hospital admissions in aggregate and per patient. We examined the distribution of costs across unique disease combinations to test the potential of the cluster approach for targeting interventions at high costs. We then estimated the overlap between the unique combinations to test potential of the cluster approach for targeting prevention of accumulated disease. We examined variability in the ranks and distributions across age (over/under 65) and deprivation (area level, deciles) subgroups and sensitivity to considering a smaller number of diseases.There were 8,440,133 unique patients in our sample, over 4 million (53.1%) were female, and over 3 million (37.7%) were aged over 65 years. No clear “high cost” combinations of multimorbidity emerged as possible targets for intervention. Over 2 million (31.6%) patients had 63,124 unique combinations of multimorbidity, each contributing a small fraction (maximum 3.2%) to current-year or 5-year secondary care costs. Highest total cost combinations tended to have fewer conditions (dyads/triads, most including hypertension) affecting a relatively large population. This contrasted with the combinations that generated the highest cost for individual patients, which were complex sets of many (6+) conditions affecting fewer persons. However, all combinations containing chronic kidney disease and hypertension, or diabetes and hypertension, made up a significant proportion of total secondary care costs, and all combinations containing chronic heart failure, chronic kidney disease, and hypertension had the highest proportion of preventable emergency admission costs, which might offer priority targets for prevention of disease accumulation. The results varied little between age and deprivation subgroups and sensitivity analyses.Key limitations include availability of data only from hospitals and reliance on hospital coding of health conditions.ConclusionsOur findings indicate that there are no clear multimorbidity combinations for a cluster-targeted intervention approach to reduce secondary care costs. The role of risk-stratification and focus on individual high-cost patients with interventions is particularly questionable for this aim. However, if aetiology is favourable for preventing further disease, the cluster approach might be useful for targeting disease prevention efforts with potential for cost-savings in secondary care.

Jonathan Stokes and co-workers explore patterns of multimorbidity and implications for the organization and costs of care.     

Ecological specialization and niche overlap of subterranean rodents inferred from DNA metabarcoding diet analysis

Knowledge of how animal species use food resources available in the environment can increase our understanding of many ecological processes. However, obtaining this information using traditional methods is difficult for species feeding on a large variety of food items in highly diverse environments. We amplified the DNA of plants for 306 scat and 40 soil samples, and applied an environmental DNA metabarcoding approach to investigate food preferences, degree of diet specialization and diet overlap of seven herbivore rodent species of the genus Ctenomys distributed in southern and midwestern Brazil. The metabarcoding approach revealed that these species consume more than 60% of the plant families recovered in soil samples, indicating generalist feeding habits of ctenomyids. The family Poaceae was the most common food resource retrieved in scats of all species as well in soil samples. Niche overlap analysis indicated high overlap in the plant families and molecular operational taxonomic units consumed, mainly among the southern species. Interspecific differences in diet composition were influenced, among other factors, by the availability of resources in the environment. In addition, our results provide support for the hypothesis that the allopatric distributions of ctenomyids allow them to exploit the same range of resources when available, possibly because of the absence of interspecific competition.     

Eyjafjallaj?kull and 9/11: The Impact of Large-Scale Disasters on Worldwide Mobility

Large-scale disasters that interfere with globalized socio-technical infrastructure, such as mobility and transportation networks, trigger high socio-economic costs. Although the origin of such events is often geographically confined, their impact reverberates through entire networks in ways that are poorly understood, difficult to assess, and even more difficult to predict. We investigate how the eruption of volcano Eyjafjallajökull, the September 11th terrorist attacks, and geographical disruptions in general interfere with worldwide mobility. To do this we track changes in effective distance in the worldwide air transportation network from the perspective of individual airports. We find that universal features exist across these events: airport susceptibilities to regional disruptions follow similar, strongly heterogeneous distributions that lack a scale. On the other hand, airports are more uniformly susceptible to attacks that target the most important hubs in the network, exhibiting a well-defined scale. The statistical behavior of susceptibility can be characterized by a single scaling exponent. Using scaling arguments that capture the interplay between individual airport characteristics and the structural properties of routes we can recover the exponent for all types of disruption. We find that the same mechanisms responsible for efficient passenger flow may also keep the system in a vulnerable state. Our approach can be applied to understand the impact of large, correlated disruptions in financial systems, ecosystems and other systems with a complex interaction structure between heterogeneous components.     

An Emergency Psychiatric Service in a General Hospital

The same extensive range of general hospital facilities should be allocated to emergency psychiatric illness as are available for other medical conditions. During the study herein reported, for every three medical consultations in the emergency ward of a large general hospital, two psychiatric consultations were requested. Over a two-year period when 24-hour coverage by psychiatric consultants was instituted, such assessments increased from 148 to 340 (during the first four months of each year); the increase in police referrals was outstanding, rising from 16 to 105. The general wards of the hospital assumed greater responsibility for further medical treatment, while committal to the mental hospital declined. Many more psychiatric patients could have been treated in the general hospital if facilities had been available. The development of an emergency psychiatric service is not an easy process and co-ordination with other psychiatric resources is required. Residents in training face situations in the emergency ward which are not encountered in any other aspect of their clinical experience.