Evaluating the effects of polices on nursing care as promoted by the Veneto region: the research protocol and its implications for public health.

Study design: Multi-centre mixed-method study design organised into several phases. Background: The Veneto region has recently defined a set of policies on nursing care by determining the needed amount of daily care in minutes and by initiating a systematic measurement of nursing outcomes; also, with a more recent policy, missed nursing care (MNC) has been established as a process measure of interest. To measure the effect of these policies, a research protocol - aimed at evaluating several end points - has been designed, involving a large target population and hospital units. The aim of this manuscript is to briefly present the research protocol and to discuss the public health implications of its expected end-points. Methods: The endpoints of the protocol are: (a) to describe the frequency of MNC as perceived by nurses; (b) to identify contributing factors; (c) to identify practices adopted in low-occurrence MNC units and to assess the effectiveness of implementing them in units with higher levels of MNC; (d) to explore the relationship between the amount of nursing care provided, MNC, and patient outcomes; and (e) to validate a tool that measures MNC as perceived by patients/caregivers. A total of 3,460 nurses, 5,000 patient/day and 160 nursing coordinators of the medical and surgical units of public hospitals in the Veneto Region will be included. Conclusions: Measuring the association between the amount of nursing care and patient outcomes, as well as evaluating the role of MNC as perceived by nurses and patients in hindering or increasing the risk of some patient outcomes can provide a body of evidence capable of further informing policies in the field, both at the national and at the international level. Moreover, emerging good practices capable of preventing or minimising MNC, sharing and implementing them in other units where high levels of missed care are reported and evaluating their effectiveness, can also inform public health policies.

Size fractionation of waste-to-energy boiler ash enables separation of a coarse fraction with low dioxin concentrations.

Polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/F) formed in modern Waste-to-Energy plants are primarily found in the generated ashes and air pollution control residues, which are usually disposed of as hazardous waste. The objective of this study was to explore the occurrence of PCDD/F in different grain size fractions in the boiler ash, i.e. ash originating from the convection pass of the boiler. If a correlation between particle size and dioxin concentrations could be found, size fractionation of the ashes could reduce the total amount of hazardous waste. Boiler ash samples from ten sections of a boiler's convective part were collected over three sampling days, sieved into three different size fractions - <0.09 mm, 0.09-0.355 mm, and >0.355 mm - and analysed for PCDD/F. The coarse fraction (>0.355 mm) in the first sections of the horizontal convection pass appeared to be of low toxicity with respect to dioxin content. While the total mass of the coarse fraction in this boiler was relatively small, sieving could reduce the amount of ash containing toxic PCDD/F by around 0.5 kg per tonne input waste or around 15% of the collected boiler ash from the convection pass. The mid-size fraction in this study covered a wide size range (0.09-0.355 mm) and possibly a low toxicity fraction could be identified by splitting this fraction into more narrow size ranges. The ashes exhibited uniform PCDD/F homologue patterns which suggests a stable and continuous generation of PCDD/F.

Nursing care as a predictor of phlebitis related to insertion of a peripheral venous cannula in emergency departments: findings from a prospective study.

BACKGROUND: To date, few studies have investigated the occurrence of phlebitis related to insertion of a peripheral venous cannula (PVC) in an emergency department (ED). AIM: To describe the natural history of ED-inserted PVC site use; the occurrence and severity of PVC-related phlebitis; and associations with patient, PVC and nursing care factors. METHODS: A prospective study was undertaken of 1262 patients treated as urgent cases in EDs who remained in a medical unit for at least 24h. The first PVC inserted was observed daily until its removal; phlebitis was measured using the Visual Infusion Phlebitis Scale. Data on patient, PVC, nursing care and organizational variables were collected, and a time-to-event analysis was performed. FINDINGS: The prevalence of PVC-related phlebitis was 31%. The cumulative incidence (78/391) was almost 20% three days after insertion, and reached >50% (231/391) five days after insertion. Being in a specialized hospital [hazard ratio (HR) 0.583, 95% confidence interval (CI) 0.366-0.928] and receiving more nursing care (HR 0.988, 95% CI 0.983-0.993) were protective against PVC-related phlebitis at all time points. Missed nursing care increased the incidence of PVC-related phlebitis by approximately 4% (HR 1.038, 95% CI 1.001-1.077). CONCLUSIONS: Missed nursing care and expertise of the nurses caring for the patient after PVC insertion affected the incidence of phlebitis; receiving more nursing care and being in a specialized hospital were associated with lower risk of PVC-related phlebitis. These are modifiable risk factors of phlebitis, suggesting areas for intervention at both hospital and unit level.

Life cycle assessment and residue leaching: the importance of parameter, scenario and leaching data selection.

Residues from industrial processes and waste management systems (WMSs) have been increasingly reutilised, leading to landfilling rate reductions and the optimisation of mineral resource utilisation in society. Life cycle assessment (LCA) is a holistic methodology allowing for the analysis of systems and products and can be applied to waste management systems to identify environmental benefits and critical aspects thereof. From an LCA perspective, residue utilisation provides benefits such as avoiding the production and depletion of primary materials, but it can lead to environmental burdens, due to the potential leaching of toxic substances. In waste LCA studies where residue utilisation is included, leaching has generally been neglected. In this study, municipal solid waste incineration bottom ash (MSWI BA) was used as a case study into three LCA scenarios having different system boundaries. The importance of data quality and parameter selection in the overall LCA results was evaluated, and an innovative method to assess metal transport into the environment was applied, in order to determine emissions to the soil and water compartments for use in an LCA. It was found that toxic impacts as a result of leaching were dominant in systems including only MSWI BA utilisation, while leaching appeared negligible in larger scenarios including the entire waste system. However, leaching could not be disregarded a priori, due to large uncertainties characterising other activities in the scenario (e.g. electricity production). Based on the analysis of relevant parameters relative to leaching, and on general results of the study, recommendations are provided regarding the use of leaching data in LCA studies.

Quality and generation rate of solid residues in the boiler of a waste-to-energy plant.

The Danish waste management system relies significantly on waste-to-energy (WtE) plants. The ash produced at the energy recovery section (boiler ash) is classified as hazardous waste, and is commonly mixed with fly ash and air pollution control residues before disposal. In this study, a detailed characterization of boiler ash from a Danish grate-based mass burn type WtE was performed, to evaluate the potential for improving ash management. Samples were collected at 10 different points along the boiler's convective part, and analysed for grain size distribution, content of inorganic elements, polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD and PCDF), and leaching of metals. For all samples, PCDD and PCDF levels were below regulatory limits, while high pH values and leaching of e.g. Cl were critical. No significant differences were found between boiler ash from individual sections of the boiler, in terms of total content and leaching, indicating that separate management of individual ash fractions may not provide significant benefits.