Metrics and Models in Software Testing

Metrics and Models in Software Testing How do we measure the progress of testing? When do we release the software? Why do we devote more time and resources for testing a particular module? What is the reliability of software at the time of release? Who is responsible for the selection of a poor test suite? How many faults do we expect during testing? How much time and resources are required to test a software? How do we know the effectiveness of test suite? We may keep on framing such questions without much effort? However, finding answers to such questions are not easy and may require significant amount of effort. Software testing metrics may help us to measure and quantify many things which may find some answers to such important questions. 10.1 Software Metrics â€Å"What cannot be measured, cannot be controlled† is a reality in this world. If we want to control something we should first be able to measure it. Therefore, everything should be measurable. If a thing is not measurable, we should make an effort to make it measurable. The area of measurement is very important in every field and we have mature and establish metrics to quantify various things. However, in software engineering this â€Å"area of measurement† is still in its developing stage and may require significant effort to make it mature, scientific and effective. 10.1.1 Measure, Measurement and Metrics These terms are often used interchangeably. However, we should understand the difference amongst these terms. Pressman explained this clearly as [PRES05]: â€Å"A measure provides a quantitative indication of the extent, amount, dimension, capacity or size of some attributes of a product or process. Measurement is the act of determining a measure. The metric is a quantitative measure of the degree to which a product or process possesses a given attribute†. For example, a measure is the number of failures experienced during testing. Measurement is the way of recording such failures. A software metric may be average number of failures experienced per hour during testing. Fenton [FENT04] has defined measurement as: â€Å"It is the process by which numbers or symbols are assigned to attributes of entities in the real world in such a way as to describe them according to clearly defined rules†. The basic issue is that we want to measure every attribute of an entity. We should have established metrics to do so. However, we are in the process of developing metrics for many attributes of various entities used in software engineering. Software metrics can be defined as [GOOD93]: â€Å"The continuous application of measurement based techniques to the software development process and its products to supply meaningful and timely management information, together with the use of those techniques to improve that process and its products.† Many things are covered in this definition. Software metrics are related to measures which, in turn, involve numbers for quantification, these numbers are used to produce better product and improve its related process. We may like to measure quality attributes such as testability, complexity, reliability, maintainability, efficiency, portability, enhanceability, usability etc for a software. We may also like to measure size, effort, development time and resources for a software. 10.1.2 Applications Software metrics are applicable in all phases of software development life cycle. In software requirements and analysis phase, where output is the SRS document, we may have to estimate the cost, manpower requirement and development time for the software. The customer may like to know cost of the software and development time before signing the contract. As we all know, the SRS document acts as a contract between customer and developer. The readability and effectiveness of SRS document may help to increase the confidence level of the customer and may provide better foundations for designing the product. Some metrics are available for cost and size estimation like COCOMO, Putnam resource allocation model, function point estimation model etc. Some metrics are also available for the SRS document like number of mistakes found during verification, change request frequency, readability etc. In the design phase, we may like to measure stability of a design, coupling amongst modules, cohesion of a module etc. We may also like to measure the amount of data input to a software, processed by the software and also produced by the software. A count of the amount of data input to, processed in, and output from software is called a data structure metric. Many such metrics are available like number of variables, number of operators, number of operands, number of live variables, variable spans, module weakness etc. Some information flow metrics are also popular like FANIN, FAN OUT etc. Use cases may also be used to design metrics like counting actors, counting use cases, counting number of links etc. Some metrics may also be designed for various applications of websites like number of static web pages, number of dynamic web pages, number of internal page links, word count, number of static and dynamic content objects, time taken to search a web page and retrieve the desired information, similarity of web pages etc. Software metrics have number of applications during implementation phase and after the completion of such a phase. Halstead software size measures are applicable after coding like token count, program length, program volume, program level, difficulty, estimation of time and effort, language level etc. Some complexity measures are also popular like cyclomatic complexity, knot count, feature count etc. Software metrics have found good number of applications during testing. One area is the reliability estimation where popular models are Musas basic executio n time model and Logarithmic Poisson execution time model. Jelinski Moranda model [JELI72] is also used for the calculation of reliability. Source code coverage metrics are available that calculate the percentage of source code covered during testing. Test suite effectiveness may also be measured. Number of failures experienced per unit of time, number of paths, number of independent paths, number of du paths, percentage of statement coverage, percentage of branch condition covered are also useful software metrics. Maintenance phase may have many metrics like number of faults reported per year, number of requests for changes per year, percentage of source code modified per year, percentage of obsolete source code per year etc. We may find number of applications of software metrics in every phase of software development life cycle. They provide meaningful and timely information which may help us to take corrective actions as and when required. Effective implementation of metrics may improve the quality of software and may help us to deliver the software in time and within budget. 10.2 Categories of Metrics There are two broad categories of software metrics namely product metrics and process metrics. Product metrics describe the characteristics of the product such as size, complexity, design features, performance, efficiency, reliability, portability, etc. Process metrics describe the effectiveness and quality of the processes that produce the software product. Examples are effort required in the process, time to produce the product, effectiveness of defect removal during development, number of defects found during testing, maturity of the process [AGGA08]. 10.2.1 Product metrics for testing These metrics provide information about the testing status of a software product. The data for such metrics are also generated during testing and may help us to know the quality of the product. Some of the basic metrics are given as: (i) Number of failures experienced in a time interval (ii) Time interval between failures (iii) Cumulative failures experienced upto a specified time (iv) Time of failure (v) Estimated time for testing (vi) Actual testing time With these basic metrics, we may find some additional metrics as given below: (i) (ii) Average time interval between failures (iii) Maximum and minimum failures experienced in any time interval (iv) Average number of failures experienced in time intervals (v) Time remaining to complete the testing. We may design similar metrics to find the indications about the quality of the product. 10.2.2 Process metrics for testing These metrics are developed to monitor the progress of testing, status of design and development of test cases and outcome of test cases after execution. Some of the basic process metrics are given below: (i) Number of test cases designed (ii) Number of test cases executed (iii) Number of test cases passed (iv) Number of test cases failed (v) Test case execution time (vi) Total execution time (vii) Time spent for the development of a test case (viii) Total time spent for the development of all test cases On the basis of above direct measures, we may design following additional metrics which may convert the base metric data into more useful information. (i) % of test cases executed (ii) % of test cases passed (iii) % of test cases failed (iv) Total actual execution time / total estimated execution time (v) Average execution time of a test case These metrics, although simple, may help us to know the progress of testing and may provide meaningful information to the testers and project manager. An effective test plan may force us to capture data and convert it into useful metrics for process and product both. This document also guides the organization for future projects and may also suggest changes in the existing processes in order to produce a good quality maintainable software product. 10.3 Object Oriented Metrics used in Testing Object oriented metrics capture many attributes of a software and some of them are relevant in testing. Measuring structural design attributes of a software system, such as coupling, cohesion or complexity, is a promising approach towards early quality assessments. There are several metrics available in the literature to capture the quality of design and source code. 10.3.1 Coupling Metrics Coupling relations increase complexity, reduce encapsulation, potential reuse, and limit understanding and maintainability. The coupling metrics requires information about attribute usage and method invocations of other classes. These metrics are given in table 10.1. Higher values of coupling metrics indicate that a class under test will require more number of stubs during testing. In addition, each interface will require to be tested thoroughly. Metric Definition Source Coupling between Objects. (CBO) CBO for a class is count of the number of other classes to which it is coupled. [CHID94] Data Abstraction Coupling (DAC) Data Abstraction is a technique of creating new data types suited for an application to be programmed. DAC = number of ADTs defined in a class. [LI93] Message Passing Coupling. (MPC) It counts the number of send statements defined in a class. Response for a Class (RFC) It is defined as set of methods that can be potentially executed in response to a message received by an object of that class. It is given by RFC=|RS|, where RS, the response set of the class, is given by [CHID94] Information flow-based coupling (ICP) The number of methods invoked in a class, weighted by the number of parameters of the methods invoked. [LEE95] Information flow-based inheritance coupling. (IHICP) Same as ICP, but only counts methods invocations of ancestors of classes. Information flow-based non-inheritance coupling (NIHICP) Same as ICP, but only counts methods invocations of classes not related through inheritance. Fan-in Count of modules (classes) that call a given class, plus the number of global data elements. [BINK98] Fan-out Count of modules (classes) called by a given module plus the number of global data elements altered by the module (class). [BINK98] Table 10.1: Coupling Metrics 10.3.3 Inheritance Metrics Inheritance metrics requires information about ancestors and descendants of a class. They also collect information about methods overridden, inherited and added (i.e. neither inherited nor overrided). These metrics are summarized in table 10.3. If a class has more number of children (or sub classes), more amount of testing may be required in testing the methods of that class. More is the depth of inheritance tree, more complex is the design as more number of methods and classes are involved. Thus, we may test all the inherited methods of a class and testing effort well increase accordingly. Metric Definition Sources Number of Children (NOC) The NOC is the number of immediate subclasses of a class in a hierarchy. [CHID94] Depth of Inheritance Tree (DIT) The depth of a class within the inheritance hierarchy is the maximum number of steps from the class node to the root of the tree and is measured by the number of ancestor classes. Number of Parents (NOP) The number of classes that a class directly inherits from (i.e. multiple inheritance). [LORE94] Number of Descendants (NOD) The number of subclasses (both direct and indirectly inherited) of a class. Number of Ancestors (NOA) The number of superclasses (both direct and indirectly inherited) of a class. [TEGA92] Number of Methods Overridden (NMO) When a method in a subclass has the same name and type signature as in its superclass, then the method in the superclass is said to be overridden by the method in the subclass. [LORE94] Number of Methods Inherited (NMI) The number of methods that a class inherits from its super (ancestor) class. Number of Methods Added (NMA) The number of new methods added in a class (neither inherited, nor overriding). Table 10.3: Inheritance Metrics 10.3.4 Size Metrics Size metrics indicate the length of a class in terms of lines of source code and methods used in the class. These metrics are given in table 10.4. If a class has more number of methods with greater complexity, then more number of test cases will be required to test that class. When a class with more number of methods with greater complexity is inherited, it will require more rigorous testing. Similarly, a class with more number of public methods will require thorough testing of public methods as they may be used by other classes. Metric Definition Sources Number of Attributes per Class (NA) It counts the total number of attributes defined in a class. Number of Methods per Class (NM) It counts number of methods defined in a class. Weighted Methods per Class (WMC) The WMC is a count of sum of complexities of all methods in a class. Consider a class K1, with methods M1,†¦Ã¢â‚¬ ¦.. Mn that are defined in the class. Let C1,†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.Cn be the complexity of the methods. [CHID94] Number of public methods (PM) It counts number of public methods defined in a class. Number of non-public methods (NPM) It counts number of private methods defined in a class. Lines Of Code (LOC) It counts the lines in the source code. Table 10.4: Size Metrics 10.4 What should we measure during testing? We should measure every thing (if possible) which we want to control and which may help us to find answers to the questions given in the beginning of this chapter. Test metrics may help us to measure the current performance of any project. The collected data may become historical data for future projects. This data is very important because in the absence of historical data, all estimates are just the guesses. Hence, it is essential to record the key information about the current projects. Test metrics may become an important indicator of the effectiveness and efficiency of a software testing process and may also identify risky areas that may need more testing. 10.4.1 Time We may measure many things during testing with respect to time and some of them are given as: 1) Time required to run a test case. 2) Total time required to run a test suite. 3) Time available for testing 4) Time interval between failures 5) Cumulative failures experienced upto a given time 6) Time of failure 7) Failures experienced in a time interval A test case requires some time for its execution. A measurement of this time may help to estimate the total time required to execute a test suite. This is the simplest metric and may estimate the testing effort. We may calculate the time available for testing at any point in time during testing, if we know the total allotted time for testing. Generally unit of time is seconds, minutes or hours, per test case. Total testing time may be defined in terms of hours. Time needed to execute a planned test suite may also be defined in terms of hours. When we test a software, we experience failures. These failures may be recorded in different ways like time of failure, time interval between failures, cumulative failures experienced upto given time and failures experienced in a time interval. Consider the table 10.5 and table 10.6 where time based failure specification and failure based failure specification are given: Sr. No. of failure occurrences Failure time measured in minutes Failure intervals in minutes 1 12 12 2 26 14 3 35 09 4 38 03 5 50 12 6 70 20 7 106 36 8 125 19 9 155 30 10 200 45 Table 10.5: Time based failure specification Time in minutes Cumulative failures Failures in interval of 20 minutes 20 01 01 40 04 03 60 05 01 80 06 01 100 06 00 120 07 01 140 08 01 160 09 01 180 09 00 200 10 01 Table 10.6: Failure based failure specification These two tables give us the idea about failure pattern and may help us to define the following: 1) Time taken to experience ‘n failures 2) Number of failures in a particular time interval 3) Total number of failures experienced after a specified time 4) Maximum / minimum number of failures experienced in any regular time interval. 10.4.2 Quality of source code We may know the quality of the delivered source code after reasonable time of release using the following formula: Where WDB: Number of weighted defects found before release WDA: Number of weighted defects found after release The weight for each defect is defined on the basis of defect severity and removal cost. A severity is assigned to each defect by testers based on how important or serious is the defect. A lower value of this metric indicates the less number of error detection or less serious error detection. We may also calculate the number of defects per execution test case. This may also be used as an indicator of source code quality as the source code progressed through the series of test activities [STEP03]. 10.4.3 Source Code Coverage We may like to execute every statement of a program at least once before its release to the customer. Hence, percentage of source code coverage may be calculated as: The higher value of this metric given confidence about the effectiveness of a test suite. We should write additional test cases to cover the uncovered portions of the source code. 10.4.4 Test Case Defect Density This metric may help us to know the efficiency and effectiveness of our test cases. Where Failed test case: A test case that when executed, produced an undesired output. Passed test case: A test case that when executed, produced a desired output Higher value of this metric indicates that the test cases are effective and efficient because they are able to detect more number of defects. 10.4.5 Review Efficiency Review efficiency is a metric that gives insight on the quality of review process carried out during verification. Higher the value of this metric, better is the review efficiency. 10.5 Software Quality Attributes Prediction Models Software quality is dependent on many attributes like reliability, maintainability, fault proneness, testability, complexity, etc. Number of models are available for the prediction of one or more such attributes of quality. These models are especially beneficial for large-scale systems, where testing experts need to focus their attention and resources to problem areas in the system under development. 10.5.1 Reliability Models Many reliability models for software are available where emphasis is on failures rather than faults. We experience failures during execution of any program. A fault in the program may lead to failure(s) depending upon the input(s) given to a program with the purpose of executing it. Hence, time of failure and time between failures may help us to find reliability of software. As we all know, software reliability is the probability of failure free operation of software in a given time under specified conditions. Generally, we consider the calendar time. We may like to know the probability that a given software will not fail in one month time or one week time and so on. However, most of the available models are based on execution time. The execution time is the time for which the computer actually executes the program. Reliability models based on execution time normally give better results than those based on calendar time. In many cases, we have a mapping table that converts execution time to calendar time for the purpose of reliability studies. In order to differentiate both the timings, execution time is represented byand calendar time by t. Most of the reliability models are applicable at system testing level. Whenever software fails, we note the time of failure and also try to locate and correct the fault that caused the failure. During system testing, software may not fail at regular intervals and may also not follow a particular pattern. The variation in time between successive failures may be described in terms of following functions: ÃŽ ¼ () : average number of failures upto time ÃŽ » () : average number of failures per unit time at time and is known as failure intensity function. It is expected that the reliability of a program increases due to fault detection and correction over time and hence the failure intensity decreases accordingly. (i) Basic Execution Time Model This is one of the popular model of software reliability assessment and was developed by J.D. MUSA [MUSA79] in 1979. As the name indicates, it is based on execution time (). The basic assumption is that failures may occur according to a non-homogeneous poisson process (NHPP) during testing. Many examples may be given for real world events where poisson processes are used. Few examples are given as: * Number of users using a website in a given period of time. * Number of persons requesting for railway tickets in a given period of time * Number of e-mails expected in a given period of time. The failures during testing represents a non-homogeneous process, and failure intensity decreases as a function of time. J.D. Musa assumed that the decrease in failure intensity as a function of the number of failures observed, is constant and is given as: Where : Initial failure intensity at the start of testing. : Total number of failures experienced upto infinite time : Number of failures experienced upto a given point in time. Musa [MUSA79] has also given the relationship between failure intensity (ÃŽ ») and the mean failures experienced (ÃŽ ¼) and is given in 10.1. If we take the first derivative of equation given above, we get the slope of the failure intensity as given below The negative sign shows that there is a negative slope indicating a decrementing trend in failure intensity. This model also assumes a uniform failure pattern meaning thereby equal probability of failures due to various faults. The relationship between execution time () and mean failures experienced (ÃŽ ¼) is given in 10.2 The derivation of the relationship of 10.2 may be obtained as: The failure intensity as a function of time is given in 10.3. This relationship is useful for calculating present failure intensity at any given value of execution time. We may find this relationship Two additional equations are given to calculate additional failures required to be experienced to reach a failure intensity objective (ÃŽ »F) and additional time required to reach the objective. These equations are given as: Where à ¢Ã‹â€ Ã¢â‚¬  ÃŽ ¼: Expected number of additional failures to be experienced to reach failure intensity objective. : Additional time required to reach the failure intensity objective. : Present failure intensity : Failure intensity objective. and are very interesting metrics to know the additional time and additional failures required to achieve a failure intensity objective. Example 10.1: A program will experience 100 failures in infinite time. It has now experienced 50 failures. The initial failure intensity is 10 failures/hour. Use the basic execution time model for the following: (i) Find the present failure intensity. (ii) Calculate the decrement of failure intensity per failure. (iii) Determine the failure experienced and failure intensity after 10 and 50 hours of execution. (iv) Find the additional failures and additional execution time needed to reach the failure intensity objective of 2 failures/hour. Solution: (a) Present failure intensity can be calculated using the following equation: (b) Decrement of failure intensity per failure can be calculated using the following: (c) Failures experienced and failure intensity after 10 and 50 hours of execution can be calculated as: (i) After 10 hours of execution (ii) After 50 hours of execution (d) and with failure intensity objective of 2 failures/hour (ii) Logarithmic Poisson Execution time model With a slight modification in the failure intensity function, Musa presented logarithmic poisson execution time model. The failure intensity function is given as: Where ÃŽ ¸: Failure intensity decay parameter which represents the relative change of failure intensity per failure experienced. The slope of failure intensity is given as: The expected number of failures for this model is always infinite at infinite time. The relation for mean failures experienced is given as: The expression for failure intensity with respect to time is given as: The relationship for additional number of failures and additional execution time are given as: When execution time is more, the logarithmic poisson model may give large values of failure intensity than the basic model. Example 10.2: The initial failure intensity of a program is 10 failures/hour. The program has experienced 50 failures. The failure intensity decay parameter is 0.01/failure. Use the logarithmic poisson execution time model for the following: (a) Find present failure intensity. (b) Calculate the decrement of failure intensity per failure. (c) Determine the failure experienced and failure intensity after 10 and 50 hours of execution. (d) Find the additional failures and additional and failure execution time needed to reach the failure intensity objective of 2 failures/hour. Solution: (a) Present failure intensity can be calculated as: = 50 failures = 50 failures = 0.01/falures Hence = 6.06 failures/hour (b) Decrement of failure intensity per failure can be calculated as: (c) Failure experienced and failure intensity after 10 and 50 hours of execution can be calculated as: (i) After 10 hours of execution (ii) After 50 hours of execution (d) and with failure intensity objective of 2 failures/hour (iii) The Jelinski Moranda Model The Jelinski Moranda model [JELI72] is the earliest and simples software reliability model. It proposed a failure intensity function in the form of Where = Constant of proportionality N = total number of errors present i = number of errors found by time interval ti. This model assumes that all failures have the same failure rate. It means that failure rate is a step function and there will be an improvement in reliability after fixing an error. Hence, every failure contributes equally to the overall reliability. Here, failure intensity is directly proportional to the number of errors remaining in a software. Once we know the value of failure intensity function using any reliability model, we may calculate reliability using the equation given below: Where ÃŽ » is the failure intensity and t is the operating time. Lower the failure intensity and higher is the reliability and vice versa. Example 10.3: A program may experience 200 failures in infinite time of testing. It has experienced 100 failures. Use Jelinski-Moranda model to calculate failure intensity after the experience of 150 failures? Solution: Total expected number of failures (N) = 200 Failures experienced (i) =100 Constant of proportionality () = 0.02 We know = 2.02 failures/hour After 150 failures = 0.02 (200-150+1) =1.02 failures/hour Failure intensity will decrease with every additional failure experience. 10.5.2 An example of fault prediction model in practice It is clear that software metrics can be used to capture the quality of object oriented design and code. These metrics provide ways to evaluate the quality of software and their use in earlier phases of software development can help organizations in assessing a large software development quickly, at a low cost. To achieve help for planning and executing testing by focusing resources on the fault prone parts of the design and code, the model used to predict faulty classes should be used. The fault prediction model can also be used to identify classes that are prone to have severe faults. One can use this model with respect to high severity of faults to focus the testing on those parts of the system that are likely to cause serious failures. In this section, we describe models used to find relationship between object oriented metrics and fault proneness, and how such models can be of great help in planning and executing testing activities [MALH09, SING10]. In order to perform the analysis we used public domain KC1 NASA data set [NASA04] The data set is available on www.mdp.ivv.nasa.gov. The 145

What i did for love :: essays research papers

You better come back here you good for nothing brat!" I covered my ears with my palms. That was my stepmother calling me. Her voice sounds murderous and I didn't want to face her today. She had slapped and hit me too much already. I'm afraid I can't take it anymore so I hid in my closet. I peeked through the crack in my closet and saw my stepmom with a really pissed off look on her face. She was holding that stick that I'm always afraid of. I was thinking about how much it would hurt if she hits me with it again. I'm just thirteen and whoever said 13 was an unlucky number, they were right. My mom had died when I was just turning ten. Before she died she told me that I was the most beautiful girl in the world and how proud she was to be my mother. She said even though she'll be gone, her love is with me always. Tears rolled down my cheeks. 'If you love me mommy, how can you be so selfish to leave me?' So now when I had turn 13 my dad had married Mok Young A, who is my stepmom today? She was a cold-hearted woman who tortured me all day. Any self-esteem I had for myself was shattered and I was living a nightmare. My closet door suddenly opened. "There you are you wicked girl!" My stepmom started cussing at me as she pulled me out and threw me onto the floor. I began to tremble because I knew what was going to happen next. *Whack whack whack. * I cried out in pain but I knew that no one is going to hear my cries. I desperately began to gasp for air. My heart was aching again. I couldn't breathe. "Not again! Don't you see how much you're costing your father and me with your heart problems? If it wasn't for all these medical bills we wouldn't be so poor now!" I had this heart condition where air would suddenly shut off and I couldn't breathe. The doctors are trying to save me by giving me a respirator and pills, but they're not sure how much longer I'll be able to live. My dad (who was a pathetic excuse for a man) came in. He looked down at me with sorrowful eyes. He held my stepmom's arm lightly and said, "I think she had enough.

Personal Narrative- Ridicule of a Child :: Personal Narrative Essays

Personal Narrative- Ridicule of a Child â€Å"Why do you ask?... Well, she’s weird.... For instance, she wears black outfits that cling to her body with red spandex.... No I’m serious. Her hair is half black and half blonde, too.... The other day she was walking down the hall with a red feathered boa wrapped around her neck.. .. Yeah, I see her every day sifting by herself in a corner all the time. . . . I guess you can’t blame her. What did happen to her when she was little?† â€Å"Oooonnnncccceeee I was at hhhhoooommmmeeee, and I ssssaaaawwww...† We despised the way her heart-shaped lips gawked open as she slurred her words. Mary Beth sounded like a lost, bleating lamb. She was the most entertaining character to imitate when my friends and I were at slumber parties. We all perfected the rhythmic pattern of her speech. And then there was her appearance. Mary Beth’s gangly body towered over the other fourth graders, and her lemon-blonde hair rested on her shoulders in knotted clumps. Strands of hair constantly fell in front of her face, and she would constantly sculpt them behind her ear. Every day she came dressed for school in brilliant colored leggings partially covered by a relaxed sweatshirt unevenly rolled at the sleeves. Her plump belly took shape under her shirts, creasing slightly, like a curtain conforming to its width. Her feet plowed into her white Keds and snuggled inside fluorescent socks scrunched at the ankle. Mary Beth’s Keds curved toward each other as she stepped, and it was evident she was pigeon-toed. (This was another characteristic we loved to imitate.) I saw her ferociously sprint during gym and on our Field Day. It was dreadful. Her leg stampeded into each other in an effort to run straight. Her arms flung back and forth anxiously like an ape’s, and I could see her tongue sticking out of her crooked mouth in determination. She was hopeless. Autumn was approaching, and so was Mary Beth’s birthday party. Incredibly, all the girls invited, including me, showed up. We even brought presents, the ones our moms had carefully picked out in consideration. We were too reluctant and far too busy with our own lives to shop for a person we mocked. The arrival of girls seemed unrealistic until I discovered why they had come. It was a party, who wouldn’t show up?

Hobbes vs. Locke Essay

Thomas Hobbes and John Locke were known as Social Contract Theorists, and Natural Law Theorists. The two men both had very strong views on freedom and how a country should be governed. Thomas Hobbes had more of a Pessimistic view while John locke had more of an Optimistic view. Hobbes and Locke believed in a type of Social Contract between the Government and being governed. Hobbes believed in Absolute Monarchs and Locke believed in the will of people being governed. Hobbes opposed constitutionalism because of his pessimistic appraisal of human nature. They both had extremely different views on government, but the bases of their arguments were similar. They both used reason to justify their ideas, rather than divine right. Although both men acknowledged that there was a God, He played a very small role in their ideologies. I believe that both Hobbes and Locke are genuinely correct. Thomas Hobbes believed mankind good and evil depended on what the individual loved and hated. He believed that life in the state of nature is â€Å"solitary, poor, nasty, brutish, and short.† (119) Mankind was naturally equal in power of mind and body so no individual was capable of dominating another. In a strictly natural condition there was no justice or injustice because everyone had their right to seek and take whatever is good and dispose of whatever was bad for them. He was for absolute monarchy. Thomas Hobbes believed that â€Å"authoritarian governments were necessary to keep human beings’ worst impulses under control.†(119) He did not believe that a large group of men would agree with one and other and peacefully run a country. Hobbes opposed constitutionalism because of his pessimistic view of human nature. The passages in Hobbes writings show that he did not desire the possibility of anything like modern totalitarianism. For Hobbes, any division of power was an invitation to chaos. Locke believed all men should be free but should some freedom be sacrificed in return for security and protection from the government. He states that Man Kind should surrender â€Å"absolute liberty in exchange for the protection of life, liberty, and the right to own property.†(125) He also believed that mankind could form a social contract together that would bring a nation together. John Locke defended the establishment of constitutional government in England and influenced the framers of the American Constitution. He believed that most people had the sense to see that others had certain rights, such as the right to life, because they were human beings. Most people were disposed to respect these rights. John Locke, the principal theorist of modern liberalism, apparently assumed that government would generally be carried on by a hereditary aristocracy. A person was not obliged to obey unless he had voluntarily agreed to do so. Thomas Hobbes and John Locke were both very intelligent Philosophers. Their beliefs in my opinion, are influential and reflect different aspects of our government today. In my opinion, it is hard to agree or disagree on some of their beliefs. Works Cited Hobbes, Thomas. â€Å"from Leviathan. â€Å" Reading The World: Ideas That Matter. 2nd Ed. Ed. Austin Michael. New York: Norton, 2010.119.Print. Hobbes, Thomas. â€Å"from Leviathan.† Reading the World: Ideas That Matter. 2nd Ed. Ed. Austin Michael. New York: Norton, 2010.125.Print.

Blood spatter Essay

Blood spatter is a common form of physical evidence at a death scene, and is often of major relevance. It is not a field in which all forensic pathologists feel confident, as in some jurisdictions it is regarded as totally within the domain of the forensic scientist and in others, the crime scene investigator. It should be reasonably regarded as a shared topic, one understood by all players, as each expert has an individual slant on the subject, and can thus provide separate insights. It is important to avoid evidence clashes. Examination and documentation of blood spatter, including what, where and how much, allows interpretation of the type and form of bleeding, and may provide a reconstruction of the incident and some surrounding circumstances. The form of report produced tends to vary with different departments, but usually is incorporated into the general scene report. Blood loss itself is due to breaches of blood vessels, and this may be due to natural disease processes or trauma. Typical examples of natural disease-causing problems at crime scenes include bleeding from a varicose skin ulcer, which is at ankle or shin level, and bleeding from lung cancer, which produces coughed-up blood. Both of these may be associated with widespread blood deposition. Commonly, these kinds of cases are associated with some degree of cleaning up or self-help, of a type consistent with a solitary life style. The type of loss is dependent on the kind of blood vessels involved. Veins return blood to the heart, operate at low pressure and flow is at a constant rate. A breach causes an ooze or pour of blood. On the other hand, arteries operate at high pressure and have a pulsatile flow. This produces a very variable flow rate, and a breach causes a spray or spurt of blood. The normal blood pressure peak and trough is 120/80mmHg at rest, but can be as high as 180-200mmHg with strenuous activity or stress, excluding any disease process. Obviously, this level may be expected in violent deaths. As veins and arteries commonly run parallel to each other, both types of vessels may be damaged at once. The size of vessel is also important, as small vessels will produce little blood, whereas the major vessels can bleed catastrophically. An arbitrary level of 200ml has been defined as the cut-off between a small and a large volume. The pathologist can rarely estimate the volume directly at the scene with any great degree of accuracy. The estimate may have to be done indirectly by crime scene examiners, such as by weighing areas of soaked carpet, and comparing this with dry areas. Classifications of Blood Stains: The appearance and the size of the blood patterns depend on the force by which they were created. When a sort of an object comes into direct contact with the blood, the force by which that object makes contact moves the blood and enhances its velocity. In some fashion the blood must react to this force transfer. Velocity is calculated in meters per second. There can be an evidence of three forms of blood spatter at a crime scene, high, medium or low blood spatter or a mix combination of these. The predictable process of categorizing blood stains was based on the connection between the speed of the force pressuring the blood drop or source that administer the individuality and dimension and distance of the resulting bloodstains. The three essential grouping of stain groups which were used based on the idea that the dimension of the blood stain being inversely comparative to the power useful to the still blood. Low Velocity Blood Spatter LVBS (Low Velocity Blood Spatters) are stains of blood which are created when the cause of blood is subjected to energy with the speed of up to 5 ft/sec. Major stains calculate normally 4mm in distance or superior. Medium Velocity Blood Spatter MVIS (Medium Velocity Blood Spatter) are stains of blood which are formed when the cause of blood is subjected to a might with a speed in between the range of 6 to 25 ft/sec. The distances of the consequential stains are in the mass range of 1 to 3 mm, even though larger and smaller bloodstains may be there. Stains in this group are normally connected with beatings and stabbings. High Velocity Blood Spatter HVBS (High Velocity Blood Spatter) are stains of blood formed when the cause of blood is subjected to a power with a speed of more than 100ft/sec. The width of the spatter is mainly less than 1mm, although larger and smaller bloodstains are frequently experiential within the outline. Bloodstains in this group are usually related with gun shots and explosions. Other device that formed bloodstains within the mass range of the usual high and medium velocities such as expiratory blood and satellite spatter bloodstains were not valued to the level that misunderstanding might and do occur. Most of the bloodstains forecasters have selected to stop this conservative terms and categorization for a more holistic advancement to bloodstain categorization. The subject that formed the rethinking of the conservative categorization of high-medium-low velocity was the diameter of sizes of stain among the high and medium velocity group and the understanding that devices other than stabbings, gunshots and beatings often formed stains with the dimension ranges within these groups. The pattern and bloodstains are confidential based on their substantial features of distribution, location, size, concentration and shape into inactive stains, splash stains or distorted stains. These are more confidential relation to method that may create stains with that uniqueness with mention to relevant scene, medicinal and case related history and facts of the proof. The forecaster than may be able to set up the exact method by which the outline was formed. More Analysis on the three classifications An abrasion or superficial laceration involves large numbers of very small to small vessels. This produces diffuse velocity from the whole area, and neither a pour nor a spray of blood would be expected. Incision of a superficial artery, such as in the wrist, involves larger vessels, with a small area of origin. This produces mainly a low velocity of blood due to pumping or spurting. A stab of a deep artery, as in the thigh, may mean involvement of a larger deep vessel. Here the presence of overlying tissues will interfere with the production of a spray, and the blood exits as a rapid pour, usually without spurting. However, there is usually still a clearly pulsatile element. But again this would be said as a low velocity blood spatter. The size of blood spots relates to the impulse of dispersal. Low velocity blood spatter such as venous bleeding, will produce large blood spots. A medium velocity blood spatter, such as produced by the use of a blunt instrument, will produce finer spots. High velocity blood spatter, as in gunshot injuries for example, will produce a fine spray. This can also be used in interpretation, as in the case of a crewman missing after an on-board explosion. There were several areas of very fine blood spray near the relevant hatch cover, and also on a broken ship’s railing. This clearly indicated that the deceased had been hit by the swinging hatch cover, and had broken the railing by force of his impact with it, during the course of being thrown overboard. Some knowledge of the injury pattern will produce the best results in interpretation. For example a slash of the neck might be expected to produce arterial spurts from large superficial vessels. A stab of chest could produce a medium flow, but if the stab is small or angulated, producing a degree of sealing, there may be little external bleeding. For example, multiple heart and aortic stabs with a skewer have been seen to produce only occasional external drops of blood. A stab of the lung may have the combination of direct bleeding from the stab and the expiration of blood mixed with air. Projected bleeding can also occur from mouth and nose following a gunshot wound of the head. During the bleeding process, the blood may be around the injury itself, and be capable of making contact impressions, or may have been projected away from the injury, and no longer be on the body at all. This blood may be around the body, and situated on bedding, furnishings, walls or carpet. The type of patterning will provide the pathologist with insights of where and how the deceased had moved. The blood may be on objects at the scene such as a weapon or a vehicle. The position, patterning and extent may indicate which part of the object caused the injury, and in turn, this may indicate the position of the deceased at the time of sustaining this injury. There may be minimal blood present at the scene, or what appears to be an inadequate amount, in view of the injuries. This may indicate that this is a secondary scene, and that the primary scene must be searched for elsewhere. Produce a fine spatter of blood at low level, with the last drops producing the greatest effect. This may outline the feet on the floor, and will also be present on the inner borders of the feet and the tops of the feet. The blood on the feet may subsequently be transferred elsewhere. The target surface is of major importance, and the effect is far less on a carpet than it would be on tiles, due to the reduced pool effect. Another significant aspect relates to blood which has been deposited from an injury onto a weapon, and is then cast off by the centrifugal force of swinging the weapon again. This may leave blood trails on ceilings or on high walls. There are various forms through which people can be killed. Listed are the few and the classification of which Velocity Blood stain it belongs to: Shootings (Medium and mostly high level Blood Spatter Velocity) Apart from the normal documentation of the scene, it is necessary to consider a number of specific matters. The pathologist must determine if the victim has moved during the course of the shooting, or has shown signs of activity afterwards. This can be done by noting the position of the body, the accessibility of the entry sites in the current body position, the presence of bullets or markings near the exit sites, and blood or tissue spatter patterns. There is usually little back spatter, but there may be considerable forward spatter, especially with more powerful weapons. It is worth bearing in mind that there may also be significant spatter extending from gas splits in the skin, and this could be at right angles to the main bullet track. Knife (Medium Velocity Blood Spatter) As mentioned above, the possibility of movement has to be considered. The volume of blood coming from an injury will depend on factors such as its type, situation and coverings, but if these are held in mind, then useful information can be gathered in order to reconstruct the incident. A knife or other sharp weapon is unlikely to cause damage to the scene, except in the most violent incidents, but it may be wiped or cleaned on the victim’s clothing or on furnishings, leaving a bloody outline. Axe (Mostly Medium Blood Spatter and at time High velocity) Because of the type of injury produced, these scenes tend to be very bloody. As there is a tendency to inflict multiple blows, there may also be evidence of the way in which these injuries were inflicted, as left by the spatter patterns. These patterns will frequently include cast-off spatter, as well as medium impulse spatter. There may even be loose fragments of soft tissue, bone or teeth. There maybe damage to the scene, particularly near to the body, due to missed hits. Fists and feet (Low velocity Blood Spatter) Assaults by kicking or stamping maybe associated with considerable contamination of the crime scene. This maybe in the form of a low-level blood spatter which may be evident up to a meter or so above ground level. Evidence of the type and position of an earlier phase of the assault is to be looked for, and blood pools that are separate from the final position of the body indicate periods of immobility. The ground surface has to be considered from the point of view of its being the possible anvil opposite some of the injuries, and thus help to interpret the assault. Footprint patterns may help to provide information as to whether bare or shod feet were used. Explosion (High Velocity Blood Spatter) Explosion scenes may extend from those where only a gram or two of explosive material is involved, to those involving tonnes of material. The pathologist’s approach will vary accordingly. Where a small quantity of material is involved, the pathologist should attempt to assess if there was any movement of the body from its original site to the point at which it is found. Blood and tissue spatter is most valuable here. The crime scene findings must be correlated with the burns and particulate damage later identified at the autopsy. The presence and role of any primary or secondary projectiles must be assessed. The author was involved in the investigation of an explosion on board a ship, where a crewman caused an explosion that blew him overboard. The body was not recovered, but damage to a hatch cover and the ships rail, both with deposition of high-impulse blood spatter and small tissue fragments indicated the extreme nature of the trauma that must have been sustained. Fragmentary body remains may be all that is recovered following a large explosion. As these may be covered with cement dust or other building materials, recognition of these remains at the scene may prove to be difficult, but this task is usually easier for a pathologist than other investigators. Work Cited Page †¢ Book Title: The Practice of Crime Scene Investigation. Contributors: John Horswell – author. Publisher: CRC Press. Place of Publication: Boca Raton, FL. Publication Year: 2004. †¢ Catten Ely (2000) Blood Spatter, What is it? From Suite 101. Retrieved on October 23, 2007, from http://www. suite101. com/article. cfm/crime_stories/34498 †¢ Louis L Akin (2005) Blood spatter interpretation at crime and accident scenes: a basic approach. (Focus on Forensics): An article from: The FBI Law Enforcement Bulletin. Publication: The FBI Law Enforcement Bulletin (Magazine/Journal) †¢ Book Title Introduction to forensic science & criminalistics (2007) Publishers McGraw-Hill †¢ James, Stuart H. (2005) Principles of bloodstain analysis; theory and practice. Publisher CRC Press †¢ Blood Spatter (2006) Department of Forensic Medicine, University of Dundee. Retrieved on October 23, 2007 from http://www. dundee. ac. uk/forensicmedicine/notes/Bloodspatter. htm †¢ Base Pair (2004), Blood Spatter Pattern Analysis. Retrieved on October 23, 2007, from http://www. tx. ncsu. edu/Science_Olympiad/Coaches_workshop/2007%20Presentations/Blood%20Spatter%20Analysis. doc †¢ Blood and Stain Analysis. Retrieved on October 23, 2007, from http://home. iprimus. com. au/ararapaj/craigslea_testbed/Forensic%20Web%20Test%20Site/blood_analysis. htm

The Use of Intraosseous Vascular Access

The Use of Intraosseous Vascular Access Table of Contents Title Page†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 1 Table of Contents†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 2 Executive Summary†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 3 Body of Paper†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 4 Plan†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã ¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 6 Do†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 7 Check†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 7 Act†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦8 Research to Support Change†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â ‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦8 Change Theory†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 6 Conclusion†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 18 References†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 20 Timeline†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚ ¬ ¦. 22 Executive Summary First introduced by Drinker and colleges in 1922, intraosseous (IO) vascular access was a method used during World War II for accessing the non-collapsible venous plexuses within the bone marrow cavity to provide access to a patient’s systemic circulation. This method later fell out of use after the development of intravenous catheters.Then during the 1980s IO vascular access was again introduced as a rapid way of gaining vascular access for swift fluid infusion particularly during resuscitation attempts of pediatric patients. (Tay & Hafeez, 2011) Plan-Being by implementing a policy for the use of IO vascular access within the Emergency Department of Hays Medical Center (HMC) for critically ill patients. This would expedite critically ill and severely injured patients in receiving the intravenous fluids and medications.Currently there is no policy in place for the placement of IO devices as opposed to peripheral intravenous catheters, or central veno us catheters. However, if there was a policy in place the staff would know when it was appropriate to insert an IO device, as opposed to having to make a difficult decision based on personal judgment. Do- Create a group of physicians and nurses to write a policy outlining when it is appropriate for the placement of an IO device compared to traditional techniques for gaining venous access. Once the policy has been written implement its use within HMC’s ED.Check- Keep a careful record of when an IO device is placed, in accordance to the new policy. Monitor the outcomes of these patients. Evaluate the effectiveness of the new policy and determine if any changes need to be made. Act- Based on the information obtained during the check phase of this project, management will determine whether the policy will be continued, improved, or discontinued. The Use of Intraosseous Vascular Access in Critically Ill Patients The origin of the intraosseous cavity as an access sight to the circu latory system was originally discovered during World War II.Medical personnel during this time used an IO route to resuscitate patients suffering from hemorrhagic shock. It was first documented in medical journals by Drinker and colleges in 1922. It was later rediscovered by American pediatrician James Orlowski. During his time working in India, Orlowski observed medical personnel during a cholera epidemic using IO access to save patients in whom IV cannulation was impossible and who might have died without access. He later wrote about his experiences in a paper entitled, My Kingdom for an Intravenous Line. Wayne, 2006) Since Dr. Orlowski brought the use of IO access in pediatrics back into the medical spotlight, the implications for its use within the adult population were soon being addressed. In 2005, the American Heart Association stated in its Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care that â€Å"IO cannulation was appropriate to provide acc ess to the non-collapsible venous plexus found in the bone marrow space, thus enabling drug delivery similar to that achieved by central venous access. (American Heart Association) Intravenous access can mean the difference between life and death when dealing with critically ill patients. IV access means that patients can receive fluids, blood products, and life-saving medications. During situations when time is precious, and access is critical is not when nurses should be making their fifth attempt at a peripheral intravenous catherization (PIV). It also shouldn’t be when chest compressions are stopped, so that the doctor can try for a central venous line (CVL).The average time necessary for PIV catherization is reported to add up to 2. 5-13 minutes and sometimes even up to 30 minutes in patients with difficult to access peripheral veins. (Leidel, Chlodwig & Bogner, 2009) This is one of many reasons why it is imperative to have a policy in place so that the staff knows that IO access should be a go to option rather than a last resort. There are very few contraindications when it comes to the placement of an IO device. However, to untrained medical personnel the thought of having to place an IO device is very daunting.I didn’t realize until this semester that it is within the scope of practice for a RN to place an IO device, but it is absolutely is! â€Å"It is the position of the Infusion Nurses Society that a qualified RN, who is proficient in infusion therapy and who has been appropriately trained for the procedure, may insert, maintain, and remove intraosseous access devices. † (â€Å"The role of,† 2009) There is also the fact that of having to explain the procedure to the patient and the patient’s family. The fear of needles is a real one.The thought of an intramuscular injection can send certain patients into a full blown panic attack. So the thought of actually having their bone pierced with a needle is a frightening o ne. Thankfully most patients who are critically ill enough to necessitate the placement of an IO device are unconscious. In cases where patients are not unconscious, an IO device can be placed with minimal discomfort if proper anesthetic techniques are used. These techniques should be taught along with placement so that nursing staff is aware of how to place an IO with minimal discomfort to the patient.It needs to be noted that â€Å"the pain associated with insertion of the EZ-IO needle is similar to that associated with insertion of a large peripheral intravenous needle and may be alleviate with infusion of lidocaine solution. † (Luck, Haines & Mull, 2010) Unlike PIVs and CVLs, IO access can be obtained from multiple sites with less chance of being unsuccessful. The locations include: proximal tibia, distal to the tibial tuberosity, distal end of the radial bone in the upper imb, proximal metaphysis of the humerus, distal tibia, proximal to the medial malleolus, distal femu r, above the femur plateau, the sternum, and also the calcaneus (Tay & Hafeez, 2011). However, IO access is typically obtained via the proximal tibia or proximal metaphysis of the humerus. There are currently three different ways to gain IO access. The first and oldest way is a manual insertion of the IO device. In this way the device is placed using the force applied by the clinician, and is done in a rotating motion. The second technique is the use of an impact device.In this case, a spring-loaded IO device is to insert the needle into the bone using direct force. The last technique is a powered drill. The small, handheld device drills the IO needle into the bone with a high-speed rotating motion. Plan To implement a policy within the Emergency Department at Hays Medical Center that clearly outlines when the placement of an intraosseous access device should be used as opposed to more traditional techniques for gaining venous access. A committee would be assembled to look at the re search on IO placement.This committee would consist of three physicians and three nurses, and will be given three months to write a policy for the department. This committee will determine in which situations an IO should be placed. The American Heart Association guidelines for intraosseous vascular access should play a major role in this decision. Once criteria has been chosen a checklist will be created that can be hung on the walls of the trauma rooms and handed out to staff. This checklist will aide in helping the staff to be able to more quickly determine in which situations placement of an IO is within the department’s policy.The appointed committee would also be in charge of deciding on which type of IO device the department should use. They will research the availability of the device chosen and what the cost will be to stock the department which the device. Do Once the research is gathered, the assigned research committee will reassemble to compose the policy that wi ll become implemented within the Emergency Department. After the policy has been written, a mandatory unit meeting will be called to introduce the new policy and answer any questions that the staff might have.During this meeting, a demonstration will be given on the correct technique for IO placement, depending on which type of device is chosen during the planning phase. After the demonstration the staff will then be asked to practice placing IO devices using practice bones. One member of the department will then be voted upon to keep track of which patients coming through the department have IO devices placed. They will keep track of for the next six months. The data collected will include any outcomes that the patient experiences, good or bad, in regards to their IO placement.Check The member of the department will look at the data collected from the outcomes of patients who had IO devices placed within the ED in the last six months. This data will then be taken back to the origin ally assigned committee. The committee will be responsible for analyzing the data. They will look at the outcomes and determine if changes need to be made to the original policy. They will also look at the outcomes to determine if there need to be changes made in the placement technique used by the department.For example, is the rate of successful placement higher or lower when done via the humerus verses the tibia? Or is there a problem with post procedural infection? Should the technique be changed from aseptic to sterile? Etc†¦ They will also ask staff within the department to fill out a survey indicating their comfort level in placing IO devices. Act Depending upon the findings of the committee they can either be decided to leave the policy in place, as is. The committee could find that the policy needs to be altered and then reviewed in another six months’ time to see if the changes were effective.Or they could find that within the ED at Hays Medical Center IO devic es for venous access should not be used although the review of literature will prove why this outcome is highly unlikely. Research to Support Change An article published in the Journal of Emergency Medicine, collaborated by three different physicians who work in Emergency Departments in Philadelphia talks about the technical side of intraosseous access. The article states that â€Å"intraosseous vascular access is indicated in the critically ill patient of any age when rapid and timely access via the intravascular route cannot be established or has failed. The article goes on to list conditions in which this might occur, including: cardiopulmonary arrest, shock, sepsis, major traumatic injuries, extensive burns or edema, and status epilepticus. (Luck, Haines & Mull, 2010) Indications may also include obese patients on who multiple PIV attempts have failed. Because studies have shown that IO infusions have the same onset of action, as that of intravenous infusions the authors recomm end that the dose used for IV fluids and medications should remain unchanged when using the IO route.They go one to state that other studies have shown that the results of several different blood test values drawn from bone marrow aspirates are comparable to those taken from venous samples. These include blood gas analysis, blood group typing, and electrolyte, drug, and hemoglobin levels. (Luck, Haines & Mull, 2010) The authors also talk about the relatively few contraindications for IO insertion. These include a fracture to the bone that the IO device is to be placed, an extremity with a vascular injury, placement to an area with an overlying skin infection or burn.IO insertion is also contraindication in patients with certain conditions that make their bones fragile such as osteogenesis imperfect and osteoporosis. The last contraindication is a new IO insertion where another IO needle may have recently been placed. This is because the opening left by the last needle can cause flui ds to extravasate. In their research of other studies, the authors found that success rates for IO insertion vary between 75%-100%, and successful infusion achieved within 30-120 seconds in the majority of cases. Luck, Haines & Mull, 2010) The most common complication was found to be extravasation of blood, fluids, and drugs into the soft tissues surrounding the site, but this occurred less than 1% of the time. With a 0. 6% chance of incidence, the most serious adverse complication was osteomyelitis. However, this was attributed to prolonged infusion. For this reason, it is recommended that the IO need be replaced by either a PIV or a CVL once the patient has stabilized and no longer than 24 hours after IO placement. (Luck, Haines & Mull, 2010)This article concluded that the use of IO access devices is a safe, reliable, and timely way of attaining vascular access. Although vital for critically ill and injured patients, it is also a technique that can be applied in non-emergent cases where multiple attempts at peripheral and central IV access has been unsuccessful. (Luck, Haines & Mull, 2010) In a study conducted by physicians at the University of Medicine Berlin’s Department of Emergency Medicine, they looked at ten consecutive adult patients who each received an IO device and also a CVC placement during a resuscitation situation.The results showed that the success rate on first attempt was 90% for IO access versus 69% for CVC placement. They also found that the mean time required for the IO access procedure was significantly shorter, 1-3 minutes, compared to the mean CVC placement time of 4-17 minutes. While conducting this study, one IO cannulation failed â€Å"due to operator mishandling by not selecting the correct insertion site at the proximal humerus. (Leidel, Chlodwig & Bogner, 2009) The physicians of this study also noted that four CVC cannulations failed on the first attempt at insertion and had to be reattempted. The study then went on to st ate that the failed placement of one IO cannulation was the only complication regarding the IO devices placed. There was â€Å"no malposition, dislodgment, bleeding, compartment syndrome, arterial puncture, haeatothorax, pneumothorax, venous thrombosis, and vascular access related infection observed. † (Leidel, Chlodwig & Bogner, 2009)In conclusion the researchers go on to state â€Å"IO vascular access is a safe, reliable, rapid option in the acute setting of adult patients under resuscitation with inaccessible peripheral veins in the emergency department†¦ Therefore, a change in practice from CVC to immediate IO access for the initial emergency resuscitation should be strongly considered as a reasonable bridging technique to increase patient’s safety in the emergency department. † (Leidel, Chlodwig & Bogner, 2009) Another study found was performed by physicians and researchers in the Department of Emergency Medicine of Singapore General hospital.It is a l arge urban hospital that handles nearly 120,000 patients annually. 9% of these patients are priority 1 patients, or patients that need resuscitation. The inclusion criteria for this study were â€Å"patients who presented to the ED with age greater than 16 years or >40kg body weight requiring intravenous fluids or medication and in whom an intravenous line could not be established in two attempts or 90 seconds. They also had to be seriously ill or injured and meet at least one or more of the following: altered mental status, respiratory compromise, haemodynamic instability, or cardiac arrest. (Ngo, Oh, Chen, Yong & Yong, 2009) The study ran from March 1, 2006 through July 30, 2007. During this time 24 patients were met the qualifications for this study. Of all the IO cannulations, only three attempts failed on the first attempt. No failures were recorded on the second attempt. The researchers also did a comparison between junior operators and senior operators and found that there w ere no disparity regarding success rates between the groups, they both had a 100% success rate. The average insertion time for both groups was approximately five seconds. Ngo, Oh, Chen, Yong & Yong, 2009) There were only two complications regarding the insertion of an IO device with this study. The first was when an operator’s glove was caught on the need during insertion. However, this could have been prevented if the operator was holding the drill properly. The other complication noted was that of extravasation of fluid at an insertion site. This is the most common type of complication, and is seen when the need is misplaced or there is an excessive amount of movement during or after the insertion. Ngo, Oh, Chen, Yong & Yong, 2009) The results of this study concluded that â€Å"the EZ-Io is a feasible, useful and fast alternative mode of venous access especially in the resuscitation of patients with no venous access or when conventional intravenous access fails. Flow rates may be improved by the use of pressure bags. Complications encountered such as extravasation of fluid and gloves being caught in the drill device can be easily prevented. † (Ngo, Oh, Chen, Yong & Yong, 2009)The third research article was a prospective, observational study conducted by researchers in the Department of Emergency Medicine at Singapore General Hospital in Singapore. The study was conducted on a convenience sample of 25 medical students, physicians and nursing staff. They were recruited to secure intraosseous access using the EZ-IO powered drill device. Unlike the previous two studies they only need to secure access on a plastic bone model rather than a live patient. (Ong, Ngo & Wijaya, 2009)The study participants were allowed multiple attempts in placement with the aim of ensuring success in placement. Their placement times were measured by an independent observer with a stopwatch, from the time the participant placed the need set into the driver and attempted to insert the needle with the ES-IO into the plastic bone. The participants then recorded their perception on the difficulty of insertion using a visual analog scale with 0 representing very easy and 10 representing very difficult placement. (Ong, Ngo & Wijaya, 2009) The results showed 96% success rate for placement.Twenty-three of the 25 participants only required one attempt at place the IO device, and only one participant was unsuccessful at securing placement of the device. This failure was attributed to â€Å"unfamiliarity with the equipment and procedure, and hesitating beyond the allocated time given for insertion. † (Ong, Ngo & Wijaya, 2009) The results of this study also showed that the mean placement time was 13. 9 seconds. The researchers also found that 87% of their participants reported that using the EZ-IO was easier compared to intravenous cannula. Ong, Ngo & Wijaya, 2009) The researchers of this study concluded that â€Å"the I/O access device (EZ-IO) evaluated in this study appears to be easy to use with high success rates of insertion with inexperienced participants. There is potential for use in the Emergency Department. (Ong, Ngo & Wijaya, 2009) The next piece of research was a randomized trial conducted by Dr. Reades from Methodist Hospital System, in Dallas, TX, Dr. Studnek from Carolinas Medical Center and the Center for Prehospital Medicine, Charlotte, NC, S.Vandeventer from Mecklenburg EMS Agency, Charlotte, NC, and Dr. Garrett from Baylor Healthcare Systems, Department of Emergency Medicine, Baylor University Medical Center, and Dallas, TX. The purpose of this study was to determine whether the tibial or humeral placement site was more effective for intraosseous placement during out-of-hospital cardiac arrest. â€Å"All patients eligible for inclusion in this study had their first attempt at vascular access randomized to one of 3 locations: proximal tibial intraosseous, proximal humeral intraosseous or peripheral intravenous. ( Reades, Studnek, Vandeventer & Garrett, 2011) Randomized note cards were distributed to the paramedic staff at the beginning of their shifts, and told them which access site was to be initially used if they came had a patient who met the inclusion criteria. There were two outcomes that were being monitored in this study. The first was a first-attempt success at the assigned method of vascular access. This qualified in one of two ways, either as an initial success or an overall success.The second measured outcome was the â€Å"total number of attempts required for successful vascular access, time to successful vascular access, time to first ACLS medication, and total volume of fluid infused during resuscitation. † (Reades, Studnek, Vandeventer & Garrett, 2011) Overall there were 182 patients randomized to one of the 3 vascular access methods. Fifty-one patients had humeral IO placements, 67 had PIV placements, and 64 had tibial IO placements. The results showed that first-atte mpt success was greatest in patients randomized to tibial IO access at 91%, compared to both humeral IO access at 51% and PIV access at 43%.The result of the secondary outcome was also significantly shorter in patients with tibial IO access. These patients had their devices in place and ready to use in an average of 4. 6 minutes. Those assigned to the humeral IO access site averaged a 7. 0 minute placement time, which was also the same time for a PIV access site. (Reades, Studnek, Vandeventer & Garrett, 2011) This study demonstrated that there is a significant different in the frequency of first-attempt success when placing tibial IO access devices as opposed to humeral IO access devices or even PIV catheters.The researchers go on to state that the â€Å"results from this study may help stakeholders such as EMS medical directors choose the most appropriate site for first-attempt vascular access†¦Ã¢â‚¬  (Reades, Studnek, Vandeventer & Garrett, 2011) The last article was a cons ortium on intraosseous vascular access in healthcare practice, published in a journal entitled critical care nurse. It too outlined the history of IO access, dating back to World War II. It discussed the clinical considerations for the use of IO access, and the clinical situations in which IO access should be considered.It went on to talk about the types of IO devices and how they’re used. It mentioned the contraindications for IO use, and also the possible complications. All of the aforementioned material was consistent with research already discussed. This article lends credibility in support of change because it discusses the education and training needed to implement IO device use in the clinical setting. It states that â€Å"to insert and maintain an intraosseous device in a patient, the clinician must demonstrate adequate knowledge and psychomotor skill competency in the procedure. (Phillips, Brown, Campbell, Miller, Proehl & Young-berg, 2010) The article then went on to discuss the economic considerations that must be looked at when considering implementing an IO insertion policy. It states that â€Å"the cost of intraosseous devices and needles should be compared with the cost of central catheter kits, ultrasound evaluation, and human resources required for their insertion. † (Phillips, Brown, Campbell, Miller, Proehl & Young-berg, 2010) The authors also note that â€Å"the economic factors must be weighed along with potential complications of therapeutic strategies should be considered. (Phillips, Brown, Campbell, Miller, Proehl & Young-berg, 2010) This article also brings to light the issue of risk management and patient safety. In this day and age where liability concerns continue to drive clinical decisions, it is important to note that delays in treatments are often cited as the cause of injury leading to malpractice claims. If there is an evidenced based option to safely and quickly provide fluid and drug resuscitation, when vascu lar access is not readily attainable, then it needs to be closely looked at.After reviewing the data the Consortium on Intraosseous Vascular Access in Healthcare Practice reached eight consensuses: 1. Intraosseous vascular access should be considered as an alternative to peripheral or central intravenous access in a variety of health care settings, including intensive care units, high acuity/progressive care units, general medical units, preprocedure surgical settings where lack of vascular access can delay surgery, and chronic care and long-term care settings, when an increase in patient morbidity or mortality is possible. . Intraosseous vascular access should be considered as part of an algorithm for patients treated by rapid response teams in whom vascular access is difficult or delayed. 3. A new algorithm that includes the intraosseous route should be developed for assessing the appropriate route of vascular access. 4. For patients not requiring placement of central catheters ei ther for long-term vascular access or hemodynamic monitoring, intraosseous access should be considered as the first alternative to failed peripheral intravenous access. 5.Techniques of intraosseous catheter placement and infusion administration should be a standard part of the medical school and nursing school curriculum. 6. In evaluating the economic implications of adopting intraosseous technology, the following should be considered: the expense of diagnostic tools to guide and confirm placement, the cost of human resources, the known and unknown risks to patient safety, and the cost of complications related to delayed treatment. 7. Organizational policies, procedures, and protocols that establish the responsibility of insertion, maintenance, and removal of intra-osseous access devices should be developed. . Further research should be conducted on, but not limited to, the safety and efficacy of use of intraosseous access in all practice settings, its economic impact on patient car e, and to support the use of intraosseous access in all health care settings. Change Theory The change theory focused upon in this paper is Gordon Lippitt’s Theory of Planned changed. According Lippitt, â€Å"Planned change or ‘neomobilistic’ change is defined as a conscious, planned effort which moves a system, an organization, or an individual in a new direction.This theory is applies because it can be applied at an individual, group, and institutional level. The basis for Lippitt’s theory of change is center around an agent for change. This agent should be a person skilled in the changed wanted to apply. It is this person who is in charge of planning for the change, initiates the change, and is credited for the accomplishment of change. Lippitt’s theory is centered around 7 phases of change. His phases are not set in stone, and there is no time frame on how long each phase should last. There should be a fluid movement back and forth between thes e seven phases.The first step is identification and diagnosis of the problem. In this case, the problem is HMC not having a firm policy in place recommending when the use of IO access devices should be implemented. The second step is the change agent assessing the client systems motivation and capacity for change. In this case, myself being the change agent, I would talk with the administrators of the ED department and determine if they agreed with my assessment for a policy to be implemented. The third step would be the initiator assesses his or her ability in helping the situation.In this case this flows back to the first step, because I saw the need for change and felt that I was equipped with the skills needed to bring about such a change. The fourth step is the change agent then chooses an appropriate role in the phase. In this case, I would choose to be part of the policy committee who is responsible for researching. The fifth step states that the change agent may be actively involved in the implementation of change, serve as an expert in fathering and providing data, or function as a liaison within the organization. I feel like in this case, I would function as a liaison within the policy making committee.The sixth step consists of maintenance of change. This involved the â€Å"Do† portion of the plan for change. This is where the decisions made by the policy are provided to the department, and the employees become responsible for implementing and maintaining the new policy. The final step is termination of the helping relationship. This step is accomplished when all parts of the PDCA plan have been completed. (Ziegler, 2005) Conclusion In a day and age where medical technology is advancing, the research about IO access devices proves that newer technologies are not always the best for a positive outcome.IO access applications have great potential in patients who are critically ill, injured, or are incapable of having PIV or CVL access. The fact that IO access is fast, reliable, and safe proves that competent placement of IO devices is a medical technique that all Emergency Departments should have in their repertoire. References (2009). The role of the registered nurse in the insertion of intraosseous access devices. Journal of infusion nursing,  32(4), 187-188. American Heart Association. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2005;112(24):57-66. Leidel, B. Chlodwig, K. , & Bogner, V. (2009). Is the intraosseous access route fast and efficacious compared to conventional central venous catherization in adult patients under resuscitation in the emergency department? a prospective observational pilot study. Patient safety in surgery,  3(24), doi: 10. 1186/1754-9493-3-24 Luck, R. , Haines, C. , & Mull, C. (2010). Intraosseous access. The journal of emergency medicine,  39(4), 468-475. Ngo, A. , Oh, J. , Chen, Y. , Yong, D. , & Yong, D. (2009). Intraosseous vascular access in adults using the ez-io in an emergency department. International journal of emergency medicine,2(3), 155-160. oi: 10. 1007/s12245-009-0116-9 Ong, M. , Ngo, A. , & Wijaya, R. (2009). An observational, prospective study to determine the ease of vascular access in adults using a novel intraosseous access device. Annals of the academy of medicine, singapore,  38(2), 121-124. Phillips, L. , Brown, L. , Campbell, T. , Miller, J. , Proehl, J. , & Young-berg, B. (2010). Recommendations for the use of intraosseous vascular access for emergent and no emergent situations in various health care settings: A consensus paper. Critical Care Nurse,  30(6), e1-e7. Reades, R. , Studnek, J. , Vandeventer, S. , & Garrett, J. (2011).Intraosseous versus intravenous vascular access during out-of-hospital cardiac arrest: A randomized controlled trial. Annals of Emergency Medicine,  58(6), 509-516. Tay, E. T. , & Hafeez, W. (2011). Intraosseous access. In R. Kulk arni (Ed. ),  Medscape reference: Drugs, disease & procedures. Retrieved from http://emedicine. medscape. com/article/80431-overview Wayne, M. (2006). Adult intraosseous access: an idea whose time has come. Israeli journal of emergency medicine,  6(2), 41-45. Ziegler, S. (2005). Theory-directed nursing practice. (2 ed. , p. 204). New York, NY: Springer Publishing Company, Inc. Timeline for Change 1/20-11/27Researched the benefits of having a policy about intraosseous access within the ED at HMC 11/28Spoke with the Director of Nursing for the ED and the Director of Emergency Medicine about my research findings 12/1A committee of three physicians and three nurses is assembled to draft a preliminary policy regarding intraosseous access 12/1-3/1The committee is given three months to compose their policy 3/2-3/10The policy is given to the Director of Nursing and Director of Emergency Medicine, who present it to the board of directors for approval 3/15A mandatory staff meeting is held outlining the new policy and answering any questions or concerns the staff has 3/16-9/16The new policy is put into effect and data is collected 9/16-10/16The original committee will analyze the data, and changes are made as needed. 10/20The final committee approved policy is present to the Director of Nursing and Director of Emergency Medicine 11/1The Director of Nursing and Director of Emergency Medicine, take the final recommendations for the policy to the hospital board of directors for approval

Choose a Technology that you think should be improved or developed Essay

Choose a Technology that you think should be improved or developed - Essay Example This later saw other manufactures come in to the field of designing better vehicles rather than a horse drawn carriage which was fitted with engine. It was until the year 2005 that the USA led the world in total automobile production. Before the great depression in 1929, the whole world is known to have had approximately 32m automobiles in operation whereby, the US contributed to 90% of this total production. (Bajaria, 2001). An automobile is a wheeled motor vehicle whose role is to transport passengers and goods from one point to another which carries its own engine. We cannot fail to mention the role which these automobiles have played towards the growth of our economies. In the field of transport, goods and services can be transported from one region to another. Trade has been enabled here between countries since goods are exported and also imported hence customers are in a position to enjoy a wide variety of products in the market. Basically, automobiles are designed to run on roads, most of them have more than one wheels, and have seats for passengers to sit on. This is one of the advanced technologies so far. This is because, you find that it is out of the introduction of these cars then that people are in a position to move from one town to another and even from one country to another. This technology has many advantages than its disadvantages though it can also be improved. Most of these vehicles move on roads and our argument here will be based on the cars which move on roads. (Bajaria, 2001). Around the whole world, there are approximately 807 million light trucks and cars in our roads. This was out of a research which was carried in a sample of countries around the world in the year 2007 which were consuming over 260 billion US gallons of diesel and gasoline fuel around the year. The table below show how important this technology has been. In India, the table below shows