ObjectiveIn 2016, a selective preventive spinal immobilization protocol for emergency medical service (EMS) nurses was introduced in the Netherlands. This protocol leaves more room for autonomous decision-making in the pre-hospital phase regarding preventive spinal immobilization (PSI), compared to the previous strict protocol. In this study, we explored the experiences and perspectives of EMS nurses on decisionmaking about PSI after the change from a strict to a selective PSI protocol. Methods: We used a qualitative design with semi-structured face-to-face interviews. Thematic analysis was applied. The capability-opportunity-motivation-behavior-model was used to interpret the experiences and perspectives. Results: Thirteen EMS nurses from three emergency medical services were interviewed. Respondents appreciated autonomous decision-making as there was more room for patient-centered informed decision-making. However, autonomous decision-making required optimized knowledge and skills and elicited the need to receive feedback on their decision not to apply PSI. When nurses anticipated resistance to selective PSI from receiving hospitals, they were doubtful to apply it. Conclusion: Nurses appreciate the increased autonomy in decision-making, encouraging them to focus on patient-centered care. Increased autonomy also places higher demands on knowledge and skills, calling for training and feedback. Anticipated resistance to receiving hospitals based on mutual protocol discrepancies could lead to PSI application by EMS nurses while not deemed necessary. Recommendations: To enhance PSI procedures, optimizing the knowledge and skills of EMS nurses that facilitate on-scene decision-making may be indicated. A learning loop for feedback between the EMS nurses and the involved hospitals may add to their professional performance. More efforts are needed to create support for the changed Emergency Medical Services strategy in PSI to prevent unnecessary PSI and practice variation.
DOCUMENT
Background: A new selective preventive spinal immobilization (PSI) protocol was introduced in the Netherlands. This may have led to an increase in non-immobilized spinal fractures (NISFs) and consequently adverse patient outcomes. Aim: A pilot study was conducted to describe the adverse patient outcomes in NISF of the PSI protocol change and assess the feasibility of a larger effect study. Methods: Retrospective comparative cohort pilot study including records of trauma patients with a presumed spinal injury who were presented at the emergency department of a level 2 trauma center by the emergency medical service (EMS). The pre-period 2013-2014 (strict PSI protocol), was compared to the post-period 2017-2018 (selective PSI protocol). Primary outcomes were the percentage of records with a NISF who had an adverse patient outcome such as neurological injuries and mortality before and after the protocol change. Secondary outcomes were the sample size calculation for a larger study and the feasibility of data collection. Results: 1,147 records were included; 442 pre-period, and 705 post-period. The NISF-prevalence was 10% (95% CI 7-16, n = 19) and 8% (95% CI 6-11, n = 33), respectively. In both periods, no neurological injuries or mortality due to NISF were found, by which calculating a sample size is impossible. Data collection showed to be feasible. Conclusions: No neurological injuries or mortality due to NISF were found in a strict and a selective PSI protocol. Therefore, a larger study is discouraged. Future studies should focus on which patients really profit from PSI and which patients do not.
DOCUMENT
In 2016, a selective preventive spinal immobilization protocol for emergency medical service (EMS) nurses was introduced in the Netherlands. This protocol leaves more room for autonomous decision-making in the pre-hospital phase regarding preventive spinal immobilization (PSI), compared to the previous strict protocol. In this study, we explored the experiences and perspectives of EMS nurses on decision making about PSI after the change from a strict to a selective PSI protocol. Methods: We used a qualitative design with semi structured face-to-face interviews. Thematic analysis was applied. The capability-opportunity-motivation behavior-model was used to interpret the experiences and perspectives. Results: Thirteen EMS nurses from three emergency medical services were interviewed. Respondents appreciated autonomous decision-making as there was more room for patient-centered informed decision-making. However, autonomous decision-making required optimized knowledge and skills and elicited the need to receive feedback on their decision not to apply PSI. When nurses anticipated resistance to selective PSI from receiving hospitals, they were doubtful to apply it. Conclusion: Nurses appreciate the increased autonomy in decision-making, encouraging them to focus on patient-centered care. Increased autonomy also places higher demands on knowledge and skills, calling for training and feedback. Anticipated resistance to receiving hospitals based on mutual protocol discrepancies could lead to PSI application by EMS nurses while not deemed necessary. Recommendations: To enhance PSI procedures, optimizing the knowledge and skills of EMS nurses that facilitate on-scene decision-making may be indicated. A learning loop for feedback between the EMS nurses and the involved hospitals may add to their professional performance. More efforts are needed to create support for the changed Emergency Medical Services strategy in PSI to prevent unnecessary PSI and practice variation.
MULTIFILE
Digital transformation has been recognized for its potential to contribute to sustainability goals. It requires companies to develop their Data Analytic Capability (DAC), defined as their ability to collect, manage and analyze data effectively. Despite the governmental efforts to promote digitalization, there seems to be a knowledge gap on how to proceed, with 37% of Dutch SMEs reporting a lack of knowledge, and 33% reporting a lack of support in developing DAC. Participants in the interviews that we organized preparing this proposal indicated a need for guidance on how to develop DAC within their organization given their unique context (e.g. age and experience of the workforce, presence of legacy systems, high daily workload, lack of knowledge of digitalization). While a lot of attention has been given to the technological aspects of DAC, the people, process, and organizational culture aspects are as important, requiring a comprehensive approach and thus a bundling of knowledge from different expertise. Therefore, the objective of this KIEM proposal is to identify organizational enablers and inhibitors of DAC through a series of interviews and case studies, and use these to formulate a preliminary roadmap to DAC. From a structure perspective, the objective of the KIEM proposal will be to explore and solidify the partnership between Breda University of Applied Sciences (BUas), Avans University of Applied Sciences (Avans), Logistics Community Brabant (LCB), van Berkel Logistics BV, Smink Group BV, and iValueImprovement BV. This partnership will be used to develop the preliminary roadmap and pre-test it using action methodology. The action research protocol and preliminary roadmap thereby developed in this KIEM project will form the basis for a subsequent RAAK proposal.
Rugpijn komt voor bij veel paarden. De pijngrens van ieder paard is verschillend, het is lastig te constateren of een paard rugpijn heeft. De oorzaken van rugpijn kunnen uiteenlopen zoals slecht passend zadel, kreupelheid, orgaanproblemen, manier van rijden, overbelasting of wervelblokkades. Momenteel wordt rugpijn geconstateerd middels handelingen zoals voelen aan spieren of wervels, visueel beoordelen van de rug. Objectieve analyses op gebied van rug problematieken en bewegingskwaliteit zijn op dit moment erg uitdagend. Het is mensenwerk en vaak zijn de meningen verdeeld zelfs tussen experts met ruime ervaring. Het equine back measurement system kan voor de sector een gamechanger worden door de mogelijkheid om de rug/romp beweging van het paard te objectiveren en kwantificeren en zodoende rugklachten te kunnen aantonen. Het equine back measurement systeem maakt met behulp van sensoren een 3D scan van het rugoppervlak tijdens bewegen (stap/draf) op een lopende band. Middels AI software analyse volgt hieruit een resultaat van de metingen en geeft het systeem aan waar opvallende afwijkingen zitten in de bewegende oppervlaktepatronen. Met deze informatie kan dan bijv. een zadelmaker het zadel op de juiste manier instellen voor het betreffende paard of zijn er indicaties voor nader veterinair onderzoek. Het equine back measurement system zou gecombineerd kunnen worden met alle bestaande lopende band opstellingen voor paarden. In de toekomst zou het systeem zelfs gebruikt kunnen worden om een nieuw te ontwikkelen zadel met luchtkamers aan te sturen. In dit project ligt de focus op genereren van een 3D model met behulp van sensoren zoals dieptecamera’s. Op basis van de ervaring met bewegingsmetingen bij paarden van projectpartner Equimoves is gebleken dat het systeem 200 - 300 metingen per seconde moet kunnen maken om voldoende details te kunnen zien. Bij dit project zijn verder betrokken Peard (zadeldrukmetingen) en Paardenkliniek Venlo.
The integration of renewable energy resources, controllable devices and energy storage into electricity distribution grids requires Decentralized Energy Management to ensure a stable distribution process. This demands the full integration of information and communication technology into the control of distribution grids. Supervisory Control and Data Acquisition (SCADA) is used to communicate measurements and commands between individual components and the control server. In the future this control is especially needed at medium voltage and probably also at the low voltage. This leads to an increased connectivity and thereby makes the system more vulnerable to cyber-attacks. According to the research agenda NCSRA III, the energy domain is becoming a prime target for cyber-attacks, e.g., abusing control protocol vulnerabilities. Detection of such attacks in SCADA networks is challenging when only relying on existing network Intrusion Detection Systems (IDSs). Although these systems were designed specifically for SCADA, they do not necessarily detect malicious control commands sent in legitimate format. However, analyzing each command in the context of the physical system has the potential to reveal certain inconsistencies. We propose to use dedicated intrusion detection mechanisms, which are fundamentally different from existing techniques used in the Internet. Up to now distribution grids are monitored and controlled centrally, whereby measurements are taken at field stations and send to the control room, which then issues commands back to actuators. In future smart grids, communication with and remote control of field stations is required. Attackers, who gain access to the corresponding communication links to substations can intercept and even exchange commands, which would not be detected by central security mechanisms. We argue that centralized SCADA systems should be enhanced by a distributed intrusion-detection approach to meet the new security challenges. Recently, as a first step a process-aware monitoring approach has been proposed as an additional layer that can be applied directly at Remote Terminal Units (RTUs). However, this allows purely local consistency checks. Instead, we propose a distributed and integrated approach for process-aware monitoring, which includes knowledge about the grid topology and measurements from neighboring RTUs to detect malicious incoming commands. The proposed approach requires a near real-time model of the relevant physical process, direct and secure communication between adjacent RTUs, and synchronized sensor measurements in trustable real-time, labeled with accurate global time-stamps. We investigate, to which extend the grid topology can be integrated into the IDS, while maintaining near real-time performance. Based on topology information and efficient solving of power flow equation we aim to detect e.g. non-consistent voltage drops or the occurrence of over/under-voltage and -current. By this, centrally requested switching commands and transformer tap change commands can be checked on consistency and safety based on the current state of the physical system. The developed concepts are not only relevant to increase the security of the distribution grids but are also crucial to deal with future developments like e.g. the safe integration of microgrids in the distribution networks or the operation of decentralized heat or biogas networks.
