The Impacts Of Ski Resorts On The Surrounding Environment Essay

The Impacts Of Ski Resorts On The Surrounding Environment - Essay Example This research will begin with the statement that the rise in tourism, and the resultant environmental and ecological inconsistencies arising out of the same, has led to an increased concern regarding the sustainability of the tourist destinations, as well as the surrounding environment. Governments, across the globe, are now increasingly and actively participating in efforts directed towards promoting eco-tourism, with a view to ensure maximum protection to the tourist destinations and to reduce the adverse environmental impacts arising out of increased human activities. There is now an increased emphasis on developing and implementing sustainable practices in ski-resorts particularly owing to the increase in ski tourism over the years. This is because Ski resorts which are mainly developed in mountainous regions where the impact of human activities is far more adverse as compared to other tourism destinations located at lower altitudes. For the purpose of this study, two qualitative research methods will be used, namely Literature review and Case study. The literature review will help in laying a basic foundation for the study, with a complete and comprehensive description of the prototypical sustainability measures that have been and can be undertaken at various levels to ensure the protection of wildlife habitat in and around ski-resorts. The validity of the claims made and observations as seen in the literature review can then be tested by way of case studies and comparing the same with other available information on ski resorts. Potential Ecological Impacts over the surroundings: The increase in human activity in mountainous regions, have contributed to the rise in global warming, primarily owing to the adverse environmental impacts caused by the development and construction of ski resorts. The constant rush of tourists, and the over the use of natural resources at popular ski resorts, take a toll on the surrounding environment, disturbing the natural habi tat in the process. Furthermore, the increasing popularity of ski resorts attracts tourists in hordes, thus leading to an increased pressure on the natural resources by way of increased demand and consumption of water, energy, and other natural resources, thus further raising deep concerns regarding its sustainability in the long run. Ski resorts, rely heavily on energy to lift and pump water to high altitudes, provide drinking water, operate heavy machinery, and fuel vehicles used for transportation. Furthermore, there are concerns regarding soil degradation caused by construction and constant human activities in ski resorts; leading to loss of vegetation, soil erosion and may lead to increased chances of floods. Flora and fauna are deeply affected due to activities such as the construction of ski slopes. The surrounding environment and the natural habitat of fauna are disturbed due to increased sound levels and noise pollution caused by tourists. Ecological Impacts on the birds' h abitat Almost all types of aspects of tourism have a direct or indirect impact on the wildlife in the surrounding areas.

S facebook a good or bad example of participatory culture Explain by Essay

S facebook a good or bad example of participatory culture Explain by connecting these ideas to your own arguments- develop and justify your own view ( write both good and bad points) - Essay Example In simpler terms, it is easily accessible. This definition brings about what is termed as participatory media. Participatory media encompasses virtual communities, video blogs just to name but a few. In this paper, one type of a participatory culture or media which is a part of social network services shall be scrutinized. Its good and bad sides as a participatory culture will be examined. The participatory culture to be looked at is Facebook (Delwiche, 2013) What makes a thing to be regarded as good? Something is regarded as good if it falls into the morally accepted or the generally accepted ideas in a society. Since its development, Facebook has been a hit in the participatory media world. It has withstood the test of time and competition. What has made Facebook a giant as a participatory culture is its good. Jenkins note that good participatory cultures are regarded good as they avail virtually low hindrances to artistic expression and civil engagement. Facebook is a good participatory culture as it provides a platform where artistic expression and civil engagement are easily expressed to a large number of people. It does this through its rather simple user interface whereby people can easily understand how it is controlled. Also, Facebook has a sharing option (Jenkins, 2013).The advantage of such an option is that people on the social networking site can easily share it with other persons. It is through this sharing that artistic ex pression and civil engagements are easily expressed to a large group of people. Facebook also allows one person to have as many friends as possible provided they know each other through friends as such. This lack of limitation as to the number of friends one can have on Facebook allows for easier expression of artistic expression and civil engagements. Facebook is also a good participatory culture in cases where its members believe their contributions matter. This is quite true for Facebook users as

Eng 105 unheard HW Essay Example | Topics and Well Written Essays - 1000 words

Eng 105 unheard HW - Essay Example Though it seems bad, the colored folk are being accepted though it a journey I know. LYON: [uncomfortable at the direction the talk is taking] It’s my music, finally started to show progress. Some producer saw me on stage at my regular club say I got talent. Next thing you know am off making something for myself. Fences is a play that focuses deeply on relationships that are strained by personal decisions and by the times they are in. the discrimination of the colored community is clearly highlighted as a theme in the play and it is portrayed as having a major role in the lives of the characters. Troy, the main character in the play, makes many mistakes in his lifetime and has learnt to live with the old ones he made as a youth. In so doing, he is able to create a family, which is relatively happy and gets a stable job. These and the friendship he has with his workmates give him something to be thankful about. The event that occurs towards the closing of the climax of the play exposes the stained relationship existing between the members of his family. Rose and Lyon have such a relationship, which is made even more difficult by introduction of Raynell in the family. Lyon and Cory are okay with each other, but there is a barrier between them where Lyon expresses a form of crippled thinking and his younger brother is more focused and sharp. In this particular instance, Lyon expresses his regard for his father when he refers his brother to their father in respect to finding a job. In this manner, he indirectly accepts that he is the one at odds with his father because he had refused an offer for a job by him. Lyon is the main focus of the act and he is exposed as having been involved with an incident he is ashamed of. He lies to his family on the source of the money he reinstates to his father knowing that if he disclosed the truth, he would be rejected. This instance goes further to show that the stereotypic

Product Life Cycle Essay Example for Free

Product Life Cycle Essay Definition: Products come and go. A company’s challenge is to hold on to its customers longer than it holds on to its products. It needs to watch the market life cycle and the customer life cycle more than the product life cycle. Someone at Ford realized this: â€Å"If we’re not customer driven, our cars won’t be either.† One selects marketing tools that are appropriate to the stage of the product’s life cycle. For example, advertising and publicity will produce the biggest payoff in the introduction stage of a product; their job is to build consumer awareness and interest. Sales promotions and personal selling grow more important during a product’s maturity stage. Personal selling can strengthen customers’ comprehension of your product’s advantages and their conviction that the offering is worthwhile. Product Development and Life-Cycle Strategies: In the face of changing customer needs, technologies and competition, product innovation or the development of new products has become vital to a companys survival. Introducing new products, however, is not sufficient. The firm must also know how to manage the new product as it goes through its life cycle: that is, from its birth, through growth and maturity, to eventual demise as newer products come along that better serve consumer needs. This product life cycle presents two principal challenges. First, because all products eventually decline, the firm must find new products to replace ageing ones (the problem of new-product development). Second, the firm must understand how its products age and adapt its marketing strategies as products pass through life-cycle stages (the problem of product life-cycle, strategies). We therefore look initially at the problem of finding and developing new products, and then at the challenge of managing them successfully over their life cycles. Innovation and New-Product Development: Given the rapid changes in taste, technology and competition, a company cannot rely solely on its existing products to sustain growth or to maintain  profitability. The firm can hope to maintain market and profit performance only by continuous product innovation. Product innovation encompasses a variety of product development activities product improvement, development of entirely new ones, and extensions that increase the range or number of lines of product the firm can offer. Product innovations are not to be confused with inventions. The latter are a new technology or product which may or may not deliver benefits to customers. An innovation is defined as an idea, product or piece of technology that has been developed and marketed to customers who perceive it as novel or new. We may call it a process of identifying, creating and delivering new-product values or benefits that were not offered before in the marketplace. In this chapter we look specifically at new products as opposed to value creation through marketing actions (such as product/brand repositioning, segmentation of current markets). We also need to distinguish between obtaining new products through acquisition by buying a whole company, a patent or a licence to produce someone elses product and through new-product development in the companys own research and development department. As the costs of developing and introducing major new products have climbed, many large companies have decided to acquire existing brands rather than to create new ones. Other firms have saved money by copying competitors brands or by reviving old brands. These routes can contribute to a firms growth and have both advantages and limitations. In this chapter, we are mainly concerned with how businesses create and market new products. By new products we mean original products, product improvements, pnxhict modifications and new brands that the firm develops through its own research and development efforts. Risks and Returns Jri Innovation Innovation can be very risky for a number of reasons: 1. New-product development is an expensive affair it cost Tate Lyle around  £150 million to develop a new sugar substitute; pharmaceutical firms spend an average of . £100-50 million to develop a new drug; while developing a super-jumbo project could cost billions. 2. New-product development takes time. Although companies can dramatically shorten their development time, in many industries, such as  Pharmaceuticals, biotechnology, aerospace and food, new-product development cycles can be as long as 10-15 years. The uncertainty and unpredictability of market environments further raise the risks of commercialization. Roots had to withdraw Manoplex, a heart drug, less than a year after its launch in the United Kingdom, after a trial on 3,000 patients in the United States and Scandinavia suggested an adverse effect on patient survival. The pharmaeeudeals division lost about  £200 million on the drug, which cost nearly  £100 million to develop over a period of 12 years, and about S20 million was spent on promoting and marketing it. 3. Unexpected delays in development are also a problem. History is littered with grand pioneering engineering projects which have failed to satisfy the original expectations of bankers, investors and politicians. The Seikan rail tunnel, connecting the island of Hokkaido to mainland Japan, was completed 14 years late and billions of pounds over budget; the S10 billion cost of the Channel tunnel, which opened on 6 May ] 994, a year later than originally planned, is more than double the  £4,8 billion forecast in 1987. 4. The new-product success record is not encouraging either. New products continue to fail at a disturbing rate. One recent study estimated that new consumer packaged goods (consisting mostly of line extensions) fail at a rate of 80 per cent. The same high failure rate appears to afflict new financial products and services, such as credit cards, insurance plans and brokerage services. Another study found that about 33 per cent of new industrial products fail at launch. Despite the risks, firms that learn to innovate well become less vulnerable to attacks by new entrants which discover new ways of delivering added values, benefits and solutions to customers problems.

Strategic Marketing by Nintendo Select an organisation

Strategic Marketing by Nintendo Select an organisation Introduction Starting out as a playing card company when it was first founded in 1889, later entered the video game industry in 1985; Nintendo has since become the leading manufacturer and distributor of video-game software and hardware (i.e. handheld consoles and static consoles). Such success has largely been attributed to Nintendos ability to develop and manage some of the most innovative products in the industry, where some still remained as one of the biggest seller of all time. Despite its success and the current position as the market leader in both the console and handheld market, Nintendo is facing increasing competition from its competitors; Microsoft and Sony, the challenges on its market from the recent recession as well as the saturation of demand of the current generation of consoles. This essay will analyse some of the main strategic marketing tools covered in the module, and then evaluate and make suggestions on how they can be used by Nintendo to manage its existing products and product portfolios or help to develop new ones. Defining product Due to the scope of the essay, the strategic marketing tools that will be analysed will be mainly related to product. A product is either tangible or intangible; it can be defined as a good, a service or even an idea or brand. It is an important factor in the marketing mix and can be a companys most important asset. A product can also be broken into three levels, core, actual and augmented (as shown in fig. 1). It is important to note that the core product is not the product itself and is not tangible; it is the basic benefits from gaining the actual product (Dibb, Simkin, Pride, Ferell, 2001). Figure Nintendo has a range of products within the video game industry, from well-known handheld consoles such as the Nintendo DS and the static video-game consoles such as the Wii, to a range of compatible video-game peripherals, accessories and software from its studios. If we take the Wii for example, the core benefit to the user would be the perceived enjoyment or fun from playing the console, the actual product would have the features of running the compatible games, while the augmented product would be the customer service and warranty the end-user could use when console breaks. Some of these products will be analysed in more detail later on using the strategic marketing tools in order to give more details on the current situation of the company and the market. The Tools There are many marketing tools and concepts nowadays to help companies assess their products and the market in order to make more informed decisions in planning. This section will concentrate on three of the strategic marketing tools relating to product as discussed within the module, with focus on the benefits and limitations of each tool when applied to Nintendo and its products. Product lifecycle Perhaps one of the more widely known tools in managing products (Dhalla Yuspeh, 2009), the product lifecycle breaks down the progress of a product developing over time into four main stages: introduction, growth, maturity, and decline. The stages can be seen on the graph in fig. 1. The first line represents the sales a company has made, while the line below is the actual profits gained after deducting all the cost. Time is represented on the horizontal axis. Figure Source: http://tutor2u.net/business/marketing/products_lifecycle.asp At introduction, despite the rapidly rising sales, it is likely that the profit remains in the negative due to the considerable costs incurred to develop and launch the new product. During the growth period, as more people become aware of the product and demand grows, sales and profit increase rapidly. After a period of time, growth in demand would start to slow as the maturity approaches. At the maturity stage, competition could be the strongest and it is also where the most profit can be earned. After the product reaches maturity, sales and profit will fall into decline as the market shrinks. By understanding the stage a companys product is at, strategic decisions can be made to minimise cost or to boost sales. Many of Nintendos products can be perceived as following such cycle. One example can be seen from Wii, one of Nintendos most success products and the current market leader in static consoles. When it was first released in 2006, there was much hype about the new product amongst the gaming community; the product was part of the seventh generation consoles, and features the distinctive motion-sensitive controllers. Although the new console lacks the graphics and processing power of its rivals, Microsofts Xbox 360 and Sonys PS3; the features of which the traditional video-gaming communities (dominated by young male gamers) have placed great emphasis on, Nintendo has dramatically increased sales by expanding the market into new consumer segments (i.e. older generations and other casual gamers) (Mintel Oxygen, 2008). In 2009, sales have slowed as the market for the current generation of consoles reaches maturity, prompting Nintendo to lower the retail price in order to boost sales (Mintel Oxygen, 2010). While the Wii seemed to be going through the stages of a product lifecycle, yet, the product lifecycle would have been too simple for Nintendo to base most of their strategies and planning on. One of its limitations is that it cannot help managers to effectively forecast sales; a reason for this would be that sales can be affected by a number of factors, internal and external. For instance, the product lifecycle could not have forecasted the recent recession which saw a cut back on spending from the casual gamers who view Wii as one of the luxury goods, thus affecting the sales. Another major limitation of the product lifecycle is that not all products will follow the typical lifecycle curve. An example can be seen from Nintendos Virtual Boy when it was first launched in 1995, the console uses a head-mounted display and controller, but since it had many technological limitations, the product did not get the sales needed and was discontinued after one year (Fletcher, 2010). Here, the product did not reach growth and maturity after introduction, and went into decline soon after. Due to its simplicities and many other limitations ( Day, 1981), some critics even argues that companies can make costly mistakes and miss opportunities if decisions are based on the product lifecycle concept, and would be better off using an information system for each product when deciding whether to promote or cut cost (Dhalla Yuspeh, 2009). Boston Matrix Developed by a large US consulting group, the Boston matrix is a strategic planning tool that base around a products market growth rate and market share when determining a marketing strategy (Donald , Hambrick, MacMillan, Diana, 1982). Each product is analysed in terms of relative market share and market growth and placed onto a matrix, where it can be classified into four categories: stars, cash cows, problem child/question mark and dogs. As seen in fig 3. Figure Source: http://www.learnpremium.co.uk/cima/lesson2/page3.aspx Stars are highly successful products with good prospects for growth and high share of the market, although they may use more cash than they generate in order to finance growth and increase capacity. Stars have the potential to become cash cows, where they have the dominant shares in the market but low growth, and more cash are generated than needed to maintain market share. With low market share and low potential for growth, products that are classified as dogs should be eliminated as they are likely to not generate cash for the company. Problem children, sometime called question marks, are products with low share of a high growth market. Some of the problem children can be turned into stars, which is why some companies still invests in them, although there is also a risk of them turning into dogs instead. The current generation consoles (the Wii and Nintendo DS range) from Nintendo can be generally be classified as cash cows, as they have the biggest share of their market but the markets are no longer growing as fast as it used to be. One of the dogs of the company would be the Game Boy Advance range (including Game Boy Advance SP and Game Boy Micro), the predecessor of the Nintendo DS range, sales and market share have dropped after the introduction of the newer versions of the DS range. An example of the question mark product would be Nintendo DSi XL, which is a newer version of the DS range that provides all the features of the Nintendo DSi along with bigger screens. It was released in November 2009, and its future is still unsure as consumers could prefer spending less on older versions that gives similar experience, rendering the DSi XL unnecessary (i.e. becoming a dog), or could potentially replace the older models and become a cash cow in future. The stars of Nintendo can be de monstrated by some of Nintendos video game software developed by its first-party studios, such as the Wii Fit, which was the third highest selling Wii game as of May 2010 (Nintendo Co., Ltd, 2010). Nevertheless, like the product life cycle model it was based on, Boston matrix, with only two dimensions (market share and market growth) is still too simplistic to use alone in making strategic decisions (Majluf, 1983). It also assumes that high market share is always related to higher rates of profit or the only success factor, and that the attractiveness of a market is not only indicated by its growth. For instance, although compared to the fast growing mainstream, casual gaming market with its large market size potential, the traditional hard-core gamer market with its narrower demographic could be seen as much less attractive. However, the latter group would also be willing to pay more for a higher specification console, and their purchase are less likely to be effected by the economic conditions in the same way that has impacted the decision of the casual gamers. Also, despite a general interpretation that dogs should be eliminated, some dog products could be part of a successf ul product mix, and their existence could serve as one of the motivating factors for consumers to purchase a particular product from the company. An example can be shown from Nintendos accessory sector, where market research has shown low market growth and low interest in accessories overall. However, many customers who chose to purchase Nintendo Wii could be influenced by the fact that parts can be replaced and purchased if required, i.e. extra controls are available for purchase should the customer want to play multi-player games. Despite its weaknesses, the Boston matrix can still serve as a simple and efficient tool to help Nintendo to predict where a product is at in its product lifecycle, for instance, question marks can be said to be on the launch stage, the stars are at the growth stage and cash cows are likely to be on the maturity stage. Ansoff Matrix The previous two marketing tools can help companies to identify the stages their products are at, but does little to help the managers formulating on a set of strategies to achieve growth. The Ansoff matrix is a tool that aids companies in making decisions on how to achieve growth depending on the product and the market it targets (Ansoff, 1965). It can be shown in a chart below, as seen in fig. 4. Figure Source: http://tutor2u.net/business/strategy/ansoff_matrix.htm The four strategic choices from the Ansoff matrix are: market penetration, product development, market development and diversification. Market penetration is considered when marketing existing products to existing consumers, this can be achieved through promotions or repositioning the brand. For instance, after it was clear that Nintendos static consoles could not compete in terms of specifications (i.e. powerful processing capacity) with Sony and Microsoft within the hard-core gaming sector (Mintel Oxygen, 2008), the company repositioned its brand to appeal more to the wider public and families in order to increase sales. Product development occurs when companies market new products in existing markets. Within the video game console market, newer models are introduced in order to compete better with the latest features on the market. Within the Nintendo DS range, new models are released almost every year; starting from the original Nintendo DS at release, then the handheld console became smaller with the DS Lite, later a webcam was added on to open up new possibilities with several games in the DSi model, and the current model, DSi XL features a bigger screen for players. All these models compete in the handheld video game console market along with Sonys PSP, with each model offering a slightly different experience to the consumer, but still in the same generation of the video game consoles (Mintel Oxygen, 2010). Market development happens when companies seek growth by introducing existing products in new markets. This can be demonstrated when companies export their products into another country or region, thereby entering a new market. Nintendos consoles and games are usually released in Japan first; the companys home market, before launching and promote them overseas. Lastly, diversification is when the company choose to market completely new products into new markets. This could be within the same industry as the existing products or going into an unrelated industry or sector. Nintendo first started out as a playing card company in the late 19th Century before it diversified into to the video gaming market by launching its first video game console, but still remained within the wider Toys and Games industry. As with the other tools, there are limitations and disadvantages on using the Ansoff matrix. Once again, the format of the two-by-two design similar to the Boston matrix can be too simplistic, and that the real-world markets and decisions are much more complex. Such as that diversification may contain many risks, i.e. lack of knowledge and experience of the new market, and that it may not be the best strategy for growth for some companies with limited resources. Also, although the Ansoff matrix can be used to identify the strategic path products may follow, and as with the Boston matrix can help simplify overly complex scenarios for easy and prompt analysis; it does not provide the marketing options which mangers will need to make based on a wider and extensive research of the company and the market. Combining the tools All the strategic marketing tools evaluated here have both benefits and disadvantages to Nintendo. Also, the market conditions can transform over time, such as changes in trend, technological advances and economic conditions (Pride Ferrell, 2008). Therefore, in order to help managers to effectively manage and develop individual products and product portfolios, the best approach will likely to involve using a number of tools. This section will look at how different marketing tools discussed previously along with other concepts can be used together by Nintendo in managing its products as well as developing new ones. Product management Product management can consist of planning, forecasting and marketing of a product in order to achieve the companys objectives. Nintendo may use the tools mentioned before to help it to paint an overall view of its products. By using the Boston matrix on all Nintendos products that are currently on the market, one can find that there are some in each of the four categories, and some may lie on the lines between two classifications. As mentioned in the introduction, the concept of product is not limited to just goods and service, and Nintendo has many products in its product portfolio. The Pokà ©mon game brand were often referred to as one of Nintendos biggest cash cows by the gaming community, with each release for various platforms and little changes to the content and gameplay providing huge profit for the company. Therefore, for the Pokà ©mon range, Nintendo may opt to spend relatively less investment in product development and promotion to maintain sales, and use the cash generated on investing in new innovations and other less successful products. The Boston matrix will also help Nintendo to identify what stage of the product lifecycle some of their products are currently in. When looking at the product lifecycle of the current generation of consoles, the slow sales growth indicates maturity of the market and the product. Therefore, Nintendo should consider developing the next generation consoles. However, care should be taken in using the product lifecycle as not all products share the same trend. To get an accurate view on what stage of the product lifecycle a console is in, and also when it will move to the next stage, instead of only relying on the Ansoff matrix and market data, Nintendo could also compare it to its predecessors, i.e. the Wii compared with Nintendo GameCube and the DS with Gameboy, as the product lifecycle of similar products within similar markets should be more closely related; though Nintendo should still be aware of some of the major differences in market and competition, such as changes in demographics of Nintendos customers and Sonys entrance into the handheld market with PSP, when comparing current generation of consoles with t he last ones. Product development Should Nintendo decide to go into product development; could be in an attempt to extend the product lifecycle of an existing product or to introduce a new product onto the market (based on Ansoff matrixs view of product development), there would also be number of considerations that needs to be taken. The company could choose to either make modifications to an existing line or to release a completely new product to replace the old one. For instance, if Nintendo want to extend the product lifecycle of its Pokà ©mon game brand by boosting sales, the company would make a new release of another version of the existing games. Such move would not require a huge investment in product development, as the concept already exist and proven to be hugely successful with a large base of loyal customers willing to get the latest version, so small changes such as packaging, improving the graphic to adapt to the latest console, and small modifications to the storyline, would be sufficient enough to release another best-selling game onto the market. Figure Developing a completely new product such as the next generation of consoles would require a much bigger investment and time. Firstly, the company will need to make sure it has done the market research required to understand the market, in order to take advantage of the companys strengths. So far, Nintendo has been successful in expanding the market by identify attracting more casual gamers from the older generation and families, thus focusing on improving gaming experience around a wider group in order to make up for its loss of appeal (due to lower performance power) from the traditional hard-core gamers. The Kanos Model as shown in fig. 5 on product development and customer satisfaction (Bergman, 2003) can be used to help Nintendo to assess the requirements of the new consoles or other products. For instance, some of the expected needs could be better graphics and performance than the previous consoles. The company may also need to assess the technology available on the market and the limitations of developing new ones. Nintendo has already announced its next generation handheld console, the Nintendo 3DS, which apparently is capable giving 3D visualisations on displays without glasses (Nintendo Co., Ltd, 2010). How well the company has evaluated its customer needs and expectations will be reflected on the success or failure (like the Virtual boy) after the product is available on the market. Conclusion Overall, the Ansoff matrix can be used as a framework for deciding upon strategies based on whether the market and the product is new or existing, the Boston matrix can be used to predict where a product is at its lifecycle based on relative market share and market growth rate, and the Product lifecycle can help companies to decide on a marketing strategy depending on the stage a product is in, although not all products go through each stage in the same way. All three tools are too simplistic and do not take into account of many real-world factors, thus extensive research on the wider market and the company is required before making strategic decisions. After evaluating the strategic marketing tools and applying them to Nintendo and its products, I believe that the best approach in managing and developing products or product portfolios is to not make judgements and strategic decisions based on one or two tools and concepts, but to use a combination of them. While managing existing products using the tools discussed here as well as extensive market research, Nintendo may decide to make modifications to its products or extend its line with a new product. Also, with the changing market conditions, Nintendo may find that it will need to change its strategic marketing approach overtime in order to adapt and manage risk to effectively manage and develop individual products and product portfolios.

David’s Oath of the Horatii :: Art Analysis History

David’s Oath of the Horatii Painted in Rome in the style of Neo-Classicism, Jacques Louis David’s Oath of the Horatii is one of the better-known examples of art produced by this artist of eclectic styles. This painting was hailed as the manifesto of a new school based on the fervent study of the antique and a return to classical techniques in the late 18th century. In this painting, completed in 1785 as an oil on canvas, David (DA-VEED) successfully coalesces the nascent and confused ideology of the Neo-Classical movement in a dramatic portrayal of the Horatii brothers swearing their allegiance to the state as their father stands with swords held high for them to grasp. An analysis of the painting’s historical background, and an evaluation of the lines, colors, and subject matter, will illustrate why Oath of the Horatii represents the defining characteristics of the Neo-Classical period. David enrolled in the Acadà ©mie Royal in 1766, when he was eighteen. In 1769 he competed for the first time in the Prix de Rome, and lost. It was not until his fifth attempt in 1774 that he finally won with his Antiochus and Stratonice. The Academy maintained a branch in Rome and winners of the Prix were sent there on a fellowship to continue their studies. David returned to France in 1779 as a well-skilled—if not yet well-known—artist and was able to display some work in the Salon. Over the next five years he gained notice as a supreme draftsman in studio nudes and as a man able to project classicism similar to Poussin. His work also appealed to the didactic philosophers of the Age of Reason. (Harber, 2) In 1784 David received a commission from the Comte d’Angiviller (the head supervisor of all build and construction under the King of France, Louis XVI) for a painting based on a Corneillian subject. Corneille’s play, Horace, was being performed in Paris at this time. Oath of the Horatii was started in Paris, but David felt he needed to be immersed in the ambiance and culture of Rome to complete it. The painting created a sensation when first exhibited in Rome of 1885, and was seen as an allegorical cry for a Revolution in France. Indeed, it was only four more years until the French Revolution was underway. The painting is now kept in the Louvre, Paris.

Healthcare-associated infections (HAIs) Essay

BACKGROUND Healthcare-associated infections (HAIs) are bacterial infections acquired during a patient’s stay in a healthcare institution.   It imposes a huge burden on healthcare institutions, costing billions of dollars for additional care costs as well as a significant fraction of lost lives (Houghton, 2006).   Current estimates depict that approximately 2 million patients acquire healthcare-associated infections (HAIs) or nosocomial infections each year, of which 90,000 to 100,000 patients die (Houghton, 2006), making HAIs not only a national health problem, but a global threat as well.   Common HAIs include hematological, surgical site, dermatological, respiratory, urinary and gastrointestinal systems.   In order to control the increase in number of healthcare-associated infections, it is fundamental to identify key factors that make healthcare institutions susceptible to such outbreaks.   There is a need to evaluate the sensitivity and efficiency of healthcare institutions to healthcare-associated infections in order to prevent future outbreaks. PROBLEM STATEMENT   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   This study will investigate the sensitivity of detection and efficiency of reporting healthcare-associated infections to the hospital administration, in the context of providing measures in improving the current surveillance program in the country.   The guidelines to identification of a healthcare associated infection will be evaluated through personal interactions with healthcare workers using questionnaires which will be designed using a multiple choice approach. CONCEPTUAL/THEORETICAL FRAMEWORK   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   This study is based on the need to address the current epidemic of healthcare-associated infection that is emerging around the world.   Before an effective solution to the problem is designed, it is essential that shortcomings in the standard procedures of healthcare institutions be identified.   This may be done by determining the level of sensitivity of healthcare personnel to symptoms of healthcare-associated infections, as well as knowing what are the first set of actions to be done once an infection is confirmed within a healthcare institution.   This study may serve as the first measurement tool that addresses these aspects of the global epidemic.    RESEARCH QUESTION/HYPOTHESIS   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   This investigation aims to address the question of whether the current hospital administration is sensitive enough to detect and substantially efficient to report to healthcare institutions any incidents of healthcare-associated infections.   This will be directly evaluated using survey data collections from retrospective cases of particular health institutions as related to dates of hospital admission, confirmation of infection and treatment time.    SIGNIFICANCE OF THE STUDY   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   There is a need for an effective surveillance and control program for healthcare-associated infections that are based on current settings in a healthcare institution.   Through surveys that inquire on common practices and responses of healthcare workers, any shortcomings or avoidable gaps in the hospital system may be reformed, which in turn will alleviate the spread of infection in the healthcare institutions.   Review of medical records and interviews with attending healthcare personnel will be performed in order to determine whether there are certain discrepancies and gaps in the healthcare protocol that facilitate contamination and further spreading of infectious microbials around the healthcare institution.   This study may facilitate the identification of key factors that influence the increase in frequency of nosocomial infections in hospitals.   The results of this investigation may positively serve as a tool to healthcare workers such as nurses and laboratory technicians. STATEMENT OF THE PURPOSE (OBJECTIVES)   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   This research will determine the sensitivity and response rate of healthcare workers to healthcare-associated infections.   This proposal aims to develop a measurement tool that will determine the sensitivity for identification, efficiency of reporting and the response rate to a healthcare-association infection, with the aim of designing a cost-effective and quick way of controlling and ultimately eradicating the healthcare-related problem.       LITERATURE REVIEW   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   The prevention and control of HAIs requires a comprehensive approach that addresses as many pathogens as possible (Wiseman, 2006). Urinary tract infections (UTI) associated with catheter use are the most common HAIs, with hospital-acquired pneumonia having the highest mortality rate (Houghton, 2006).   These infections are frequently problematic to treat due to the fact that the microorganisms involved have become resistant to antibiotics (Broadhead, Parra and Skelton, 2001). Recent media coverage of meticillin-resistant Staphylococcus aureus (MRSA) has increased the awareness of healthcare professionals to the threat of this particular microbe.   S. aureus infections can result in cellulitis, osteomyelitis, septic arthritis and pneumonia, and some of the systemic diseases such as food poisoning, scalded skin syndrome and toxic shock syndrome (Zaoutis, Dawid and Kim, 2002).   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   MRSA and vancomycin-resistant Enterococcus (VRE) are the primary causes of nosocomial infections and are significant factors in increased morbidity and mortality rates. These microbes are currently endemic in many healthcare institutions, particularly problematic in intensive care units (ICUs) (Furuno, et al. 2005).   VRE Infections have become prevalent in U.S. hospitals over the last decade, increasing in incidence 25-fold (Ridwan et al., 2002).   Vancomycin is the antibiotic frequently used to treat infections caused by MRSA, but recent years have seen the emergence of Staphylococcus aureus infections that have high-resistance to vancomycin, which makes the future effectiveness of this drug questionable (Furuno et al., 2005). All known variants of the vancomycin-resistant Staphylococcus aureus (VRSA) isolates have possessed the vanA gene, which carries with it resistance to vancomycin.   This development is believed to have been acquired â€Å"when the MRSA isolate conjugated with a co-colonizing VRE isolate† (Furuno et al., 2005, p. 1539). This means that patients who suffer co-colonization from MRSA and VRE have an increased risk for colonization and infection by VRSA (Furuno et al., 2005). Furthermore, Zirakzadeh and Patel (2006) stated that VRE has become a major concern due, in part, to its ability to transfer vancomycin resistance to other bacteria, which includes MRSA.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Infection of susceptible patients typically occurs in environments that have a high rate of patient colonization with VRE, such as ICUs and oncology units (Zirakzadeh and Patel, 2006).   In these healthcare settings, VRE has been known to survive for extensive periods and research has also observed that VRE has the ability to contaminate virtually every surface (Zirakzadeh and Patel, 2006). Efforts to control HAIs, such as VRE, have focused on prevention, such as through hand hygiene, as the first line of defense.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Hand hygiene has been improved by using â€Å"user-friendly, alcohol-based hand cleansers, but there still remains the goal of achieving consistently high levels of compliance with their use† (Carling et al., 2005, p. 1).   Screening-based isolation practices have likewise improved transmission rates of MRSA and VRE; however, logistic issues and the cost-effectiveness of these practices are still being analyzed (Carling et al., 2005). Additionally, despite isolation practices, outbreaks and instances of environmental contamination have been documented in regards to MRSA, VRE and Clostridium difficile, which cannot be screened with any practicality (Carling et al., 2005).   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   The numerous obstacles that exist in regards to effective screening practices suggest that a focus on improving existing cleaning/disinfecting practices may prove to be more effective in halting the spread of HAIs (Carling et al., 2005). Studies over the last several decades have shown that there is often contamination of surfaces in and around the patient, as pathogens associated with the hospital environment have been known to survive on surfaces for weeks or even months (Carling et al., 2005). Significant rates of contamination with Clostridium difficile have been connected with symptomatic and asymptomatic patients (Carling et al., 2005).   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   In 2002, the CDC issued guidelines that called for hospitals to â€Å"thoroughly clean and disinfect environmental medical equipment† surfaces on a regular basis (Carling et al., 2005, p. 2). Other organizations have followed suit and stressed repeatedly the need for healthcare provides to focus on environmental cleaning and disinfecting activities, yet these guidelines have not provided directives that address precisely how healthcare providers can either evaluate   their ability to comply with professional guidelines on this topic or ensure that their procedures are effective (Carling et al., 2005).   Nevertheless, literature on the subject does offer some guidance.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Surveillance, evidence-based infection control practices and the responsible use of antibiotics have been determined to be crucial to controlling HAIs (Wiseman, 2006).   The establishment of comprehensive surveillance programs has facilitated the creation of national databases the compile cases of infection which may be useful to researchers investigating progression rates and causal factors.   Evidence-based control practices may be implemented by distributing guidelines for aseptic hospital protocols, hospital hygiene, personal protective equipment and disposal of biohazardous sharps.   A review of commonly used antibiotics in terms of proper dosage and length of treatment based on clinical evidence and best practice guidance should also be performed.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Curry and Cole (2001) reported that the medical and surgical ICUs in large inner-city teaching hospitals developed an elevated patient VRE colonization rate. A multi-faceted approach was instituted to correct this problem, which involved changing behavior by â€Å"shifting norms at multiple levels through the ICU community† (Curry and Cole, 2001, p. 13). This intervention consisted of five levels of behavioral change. These encompassed: â€Å"1. intrapersonal and individual factors; 2. interpersonal factors; 3. institutional factors; 4. community factors and 5. public factors† (Curry and Cole, 2001, p. 13).   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Educational interventions were developed that addressed each level of influence and behavioral change was predicated on â€Å"modeling, observational learning and vicarious reinforcement† (Curry and Cole, 2001, p. 13). These procedures resulted in a marked decrease of â€Å"VRE surveillance cultures and positive clinical isolates† within six months and this decrease has been consistent over the next two years (Curry and Cole, 2001, p. 13).   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Research has shown that the nutritional status of preoperative and perioperative patients can influence their risk for acquiring a HAI (Martindale and Cresci, 2005). This is particularly true for patients who are undergoing surgery for neoplastic disease as this can commonly result in immunosuppression (Martindale and Cresci, 2005). Inadequate nutrition, â€Å"surgical insult, anesthesia, blood transfusions, adjuvant chemotherapy/radiation/ and other metabolic changes† have been identified as contributing to suppression of the immune system (Martindale and Cresci, 2005). Furthermore, studies have also associated infection risk with glycemic control Maintaining blood glucose levels between 80 and 110 mg/dL vs. 180 and 200 mg/dL has been shown to result in fewer instances of â€Å"acute renal failure, fewer transfusions, less polyneuroopathy and decreased ICU length of stay† (Martindale and Cresci, 2005, p. S53).   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Citing Ulrich and Zimring, Rollins (2004) states that getting rid of double-occupancy rooms and providing all patients with single rooms that can be adjusted to meet their specific medical needs can improve patient safety by reducing patient transfers and cutting the risk of nosocomial infections. While these researchers admit that the up-front cost of private rooms is significant, this will be offset by the savings accrued through lowers rates of infection and readmission, as well as shorter hospital stays (Rollins, 2004).   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   A recent study conducted by researchers at Chicago’s Rush University Medical Center found that enforcing environmental cleaning standards on a routine basis resulted in less surface contamination with VRE, â€Å"cleaner healthcare worker hands, and a significant reduction in VRE cross-transmission in an ICU† (Cleaning campaign, 2006, p. 30). These improvement in VRE contamination continued to be experienced even when VRE-colonized patients were continually admitted and healthcare workers compliance with hand hygiene procedures were only moderate (Cleaning campaign, 2006). The strategies that the researchers implemented included that they: held in-services for housekeepers about why cleaning is important–emphasizing thorough cleaning of surfaces likely to be touched by patients or workers. increased monitoring of housekeeper performance. recruited respiratory therapists to clean ventilator control panels daily. educated nurses and other ICU staff on VRE and how they could assist housekeepers by clearing surfaces that need cleaning. conducted a hand hygiene campaign, including: mounting alcohol gel dispensers in common areas, patient rooms and every room entrance (Cleaning campaign, 2006, p. 30).   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   CDC guidelines indicate that if hands are not visibly soiled, using an alcohol-based hand rub should become habitual between patient contacts. When hands are visibly soiled, use of an anti-microbial soap and water is required. If contact with C difficile or Bacillus anthracis is possible, it is recommended that the healthcare provider wash with anti-microbial soap and water, as other antiseptic agents have poor efficacy against spore-forming bacteria and the physical friction of using soap and water at least decreases the level of contamination (Houghton, 2006). Page (2005) indicates that the CDC has joined with the US Department of Health and Human Services, the National Institutes of Health (NIH and the Food and Drug Administration (FDA) to lead a task force of 10 agencies and departments, which have developed a blueprint outlining federal actions to combat this problem. This template emphasizes the efficacy of hand washing, among other points (Page, 2005).   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   In 2002, the CDC issued updated hand hygiene guidelines, which address new development and research on this topic, such as â€Å"alcohol-based hand rubs and alternatives to antibacterial soaps and water† (Houghton, 2006, p. 2). However, while the efficacy of hand hygiene is well accepted, it is also well known that healthcare workers â€Å"of all disciplines† frequently fail to abide by adequate hand hygiene practices (Houghton, 2006, p. 2). In fact, research has shown that adherence rates to hand hygiene guidelines are lowest in ICUs, where to the frequency of patient care contact, multiple opportunities for hand hygiene exist on a hourly basis (Houghton, 2006). According to Houghton (2006), any direct patient-care contact, which includes contact with gloves and/or contact with objects in the immediate patient vicinity, constitutes an â€Å"opportunity† for appropriate hand hygiene.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   This suggests that the proposed intervention should also include asking healthcare employees at the site of the intervention to participate in a survey that examines, first of all, how closely hand hygiene protocols are followed and, if they are not followed, why not. It may be that the activity level of ICUs is so great that the practitioners feel that they cannot take sufficient time to do adequate hand hygiene. If this is the case, alternative methods of hand hygiene to that institution’s traditional policy may need to be investigated.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Just as this study revealed factors that can be associated with non-compliance, a similar investigative effort may be called for to determine reasons why compliance may not be satisfactory for cleaning/disinfecting environmental surfaces. Again, it may be that non-compliance hinges on factors of time.   It may be, therefore, expeditious for hospitals and other healthcare organizations to look into hiring additional personnel to aid with cleaning/disinfecting tasks. It may also prove necessary, to cope with factors of time and efficiency, to train cleaning personnel to take a systematic approach to patient room cleaning that includes all â€Å"high touch† areas. As noted previously, researchers at Chicago’s Rush University Medical Center found that holding in-service training for housekeepers was an effective component of their overall strategy in lowering VRE related infections (Cleaning campaign, 2006). This process could be facilitated by a checklist approach or by periodically reevaluating rooms according to the Carling et al. (2005) methodology.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Given these detailed accounts of healthcare-associated infections in hospitals, it is of significant importance that the sensitivity and response rate of health personnel be identified in order to know if there are any discrepancies and gaps in the standard hospital protocols that foster the expansion of microbials in hospitals.   This study aims to determine the level of sensitivity and response rate of healthcare institutions to the growing epidemic of healthcare-associated infections.    SUMMARY   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   HAIs are an unnecessary tragedy, increasing morbidity and mortality figures and adding to healthcare costs. While there are ways to treat all the various HAIs, the clearest remedy for this insidious drain on healthcare resources and personnel is prevention, which begins with the simplest of acts–washing one’s hands–but also extends to considering all hospital surfaces as having the potential to harbor pathogens. This means rethinking some healthcare institutional procedures. It means habitually and routinely cleaning all surfaces, as well as everywhere and anything that is routinely touched, whether by a bare or gloved hand.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Stopping the spread of HAIs includes multiple factors, such as restrained and appropriate use of antibiotics. However, the first line of defense is cleaning/disinfecting procedures. This constitutes the â€Å"ground zero† foundational line for battling HAIs and this means that all healthcare practitioners should keep the goal of reducing the spread of HAIs foremost in their minds while going about their daily routines, washing hands between each patient contact and paying attention to other sepsis concerns. In other words, the first step in stopping HAIs is simply to keep them in the forefront of practitioner consciousness. References Broadhead, J. M., Parra, D. S., & Skelton, P. A. (2001). Emerging multiresistant organisms in the ICU: Epidemiology, risk factors, surveillance, and prevention. Critical Care Nursing Quarterly, 24(2), 20. Carling, P. C., Briggs, J., Hylander, D., & Perkins, J. (2006). An evaluation of patient area cleaning in 3 hospitals using a novel targeting methodology. American Journal of Infection Control, 34(8), 513-519. Centers for Disease Control and Prevention. (2006). Healthcare-Associated Infections (HAIs).  Ã‚   Retrieved March 17, 2007, from http://www.cdc.gov/ncidod/dhqp/healthDis.html Cleaning campaign targets VRE transmission. (2006). OR Manager, 22(7), 30. Curry, V. J., & Cole, M. (2001). Applying social and behavioral theory as a template in containing and confining VRE. Critical Care Nursing Quarterly, 24(2), 13. Furuno, J. P., Perencevich, E. N., Johnson, J. A., Wright, M.-O., McGregor, J. C., Morris Jr, J. G., et al. (2005). Methicillin-resistant Staphylococcus aureus and Vancomycin-resistant Enterococci co-colonization. Emerging Infectious Diseases, 11(10), 1539-1544. Harrison, S., & Lipley, N. (2006). Wipe It Out infection control initiative extended. Nursing Management – UK, 12(10), 4-4. Houghton, D. (2006). HAI prevention: The power is in your hands. Nursing Management, 37(5), 1-8. Johnson, A.P. Pearson, A. and Duckworth, G.   (2005):   Surveillance and epidemiology of MRSA bacteraemia in the UK.   J. Antimicrob. Chemo.   56:455–462. Lopman, B.A., Reacher, M.H., Vipond, I/.B., Hill, D., Perry, C., Halladay, T., Brown, D.W., John Edmunds, W. and Sarangi, J.   (2004):   Epidemiology and Cost of Nosocomial Gastroenteritis, Avon, England, 2002–2003.   Emerg. Infect. Dis.   10(10):1827-1834. Martindale, R. G., & Cresci, G. (2005). Preventing Infectious Complications With Nutrition Intervention. JPEN, Journal of Parenteral and Enteral Nutrition, 29(1), S53. Page, S. (2005). MRSA, VRE and CDC’s plan to combat antimicrobial resistance. Vermont Nurse Connection, 8(3), 6-7. Parienti, J. J. M. D. D. T. M., Thibon, P. M. D., Heller, R. P. P., Le Roux, Y. M. D. D., von Theobald, P. M. D. D., Bensadoun, H. M. D. D., et al. (2002). Hand-rubbing with an aqueous alcoholic aolution vs traditional surgical hand-scrubbing and 30-day surgical site infection Rates. JAMA, 288(6), 722-727. Ridwan, B., Mascini, E., Reijden, N. v. d., Verhoef, J., & Bonten, M. (2002). What action should be taken to prevent spread of vancomycin resistant enterococci in European hospitals? British Medical Journal, 324(7338), 666. Rollins, J. A. (2004). Evidence-Based Hospital Design Improves Health Care Outcomes for Patients, Families, and Staff. Pediatric Nursing, 30(4), 338. Sheff, B. (2001). Taking aim at antibiotic-resistant bacteria. Nursing, 31(11), 62. STATA 8.0. College Station (TX): STATA Corporation; 2002. Stevenson, K.B., Searle, K., Stoddard, G.J. and Samore, M.H. (2005):   Methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococci in rural communities, Western United States.   Emerg. Infect. Dis.   11(6):895-903. Tacconelli, E. Venkataraman, L., De Girolami, P.C. and D’Agata, E.M.C.   (2004):   Methicillin-resistant Staphylococcus aureus bacteraemia diagnosed at hospital admission: distinguishing between community-acquired versus healthcare-associated strains.   J. Antimicrob. Chemother. 53:474-479. Wiseman, S. (2006). Prevention and control of healthcare associated infection. Nursing Standard, 20(38), 41-45. Zaoutis, T., Dawid, S., & Kim, J. O. (2002). Multidrug-resistan organisms in general pediatrics. Pediatric Annals, 31(5), 313. Zirakzadeh, A., & Patel, R. (2006). Vancomycin-resistant enterococci: Colonization, infection, detection and treatment. Mayo Clinical Proceedings, 81(4), 529-536. METHODOLOGY   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   A retrospective non-probability cluster surveillance study will be performed on hospital records of two health institutions, Assir Central Hospital and Khamis Mushait Hospital from January 2002 to December 2006.   Such coverage will represent a larger population of similar environmental and socioeconomic settings, which may also influence the frequency of healthcare-associated infections in the area.   This type of non-probability cluster sampling will be used because it will benefit the split-level definition that will be followed, distinguishing normal hospital cases and healthcare-associated infections or outbreaks, based on the CDC’s guidelines for healthcare-associated infections.   Ethical approval from the respective ethics review committee of each hospital will be obtained before the study will be conducted. Study population.   ThÐ µ study population will includÐ µ 5,000 patiÐ µnts that have been admitted at the Assir Central Hospital and Khamis Mushait Hospital from January 2002 to December 2006.   These hospitals were chosen in order to primarily focus on collection of reliable, high-quality data based of systematic sampling.   The hospital’s administrative database will serve as the main source of information for this study.   For purposes of anonymity, patient’s names will be kept confidential and will be replaced with a case number instead.   A retrospective non-probability sampling using patiÐ µnt cases will be classified according to gender, age, diagnosis upon admission, length of stay and treatment received. The treatment category of the patients will be further characterized as surgical, respiratory, urinary, urological, obstÐ µtrical, intensive care, cardiac or trauma.   Any co-morbidities will be taken note of in every patient included in the study.   Patient records will also be reviewed to determine whether and when a healthcare-associated infection was observed after admission to the hospital or during the patient’s stay in the hospital and will be identified as the time-at-risk, or the time when the infection has been ascertained and may most probably be contagious to the patient’s immediate environment.   Among the inclusion subjects are healthcare workers such as nurses, laboratory technicians and other hospital staff members will be included in the study as population at risk.   Exclusion subjects are those patients that were not admitted into the hospital because their stay in the hospital was not recommended during their healthcare.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   The database of the infection control team of each of the two hospitals will be reviewed to gather information on the study population in the hospitals.   Infection control nurses are responsible for monitoring any outbreaks in each hospital during hospital ward rounds, or are identified as the point-of-contact personnel that is alerted as soon as an HAI incident is suspected to occur in the specific ward of the hospital.   Cluster sampling will be performed when an infection does happen that fits the clinical definition of an HAI, the healthcare institution is required to report this incident to the area’s or county’s health protection agency.   The area or county health protection agency is in charge of ensuring the comprehensiveness of incident reports, monitoring data entry and conducting analyses.   The health protection agency also collects reports during months that no infections were reported to verify that no inf ections occurred at that time. Tools to be employed.   To determine whether a case patient has contracted a healthcare-associated infection, the system definitions established by the Center for Disease Control and Prevention’s National Nosocomial Infection Surveillance (NNIS) will be followed, with slight modification for usÐ µ in a rÐ µtrospÐ µctivÐ µ study.   ThÐ µ NNIS dÐ µfinitions were dÐ µvÐ µlopÐ µd according to a prospÐ µctivÐ µ approach to hospital survÐ µillancÐ µ and arÐ µ dÐ µsignÐ µd to bÐ µ quitÐ µ spÐ µcific.   BÐ µcausÐ µ clinical dÐ µcisions arÐ µ oftÐ µn not madÐ µ on thÐ µ basis of survÐ µillancÐ µ dÐ µfinitions, wÐ µ bÐ µliÐ µvÐ µ that somÐ µ casÐ µs of clinically suspÐ µctÐ µd infÐ µction would mÐ µÃ µt most but not all of thÐ µ NNIS critÐ µria and thus bÐ µ classifiÐ µd as non-HAI, Ð µspÐ µcially on a rÐ µtrospÐ µctivÐ µ chart rÐ µviÐ µw. WÐ µ designed a retrospective-based data classification scheme that follows the following criteria: patiÐ µnts who were not infÐ µctÐ µd, thosÐ µ with suspÐ µctÐ µd HAI, and thosÐ µ with confirmÐ µd HAI.   In gÐ µnÐ µral, patiÐ µnts with suspÐ µctÐ µd HAI will includÐ µ thosÐ µ who have received antimicrobial thÐ µrapy for a condition that appÐ µarÐ µd 148 h aftÐ µr hospital admission and who will mÐ µÃ µt all but onÐ µ clinical critÐ µria for a confirmed infÐ µction.   DÐ µfinitions for a confirmed HAI will bÐ µ the samÐ µ as thosÐ µ usÐ µd by thÐ µ NNIS, Ð µxcÐ µpt that rÐ µcÐ µipt of appropriatÐ µ antimicrobial thÐ µrapy will bÐ µ Ð µxcludÐ µd as a critÐ µrion for a confirmÐ µd infÐ µction. ThÐ µsÐ µ critÐ µria will bÐ µ finalizÐ µd bÐ µforÐ µ chart data abstraction bÐ µgins.   ThÐ µ Ð µconomic pÐ µrspÐ µctivÐ µ will bÐ µ usÐ µd for mÐ µasuring costs incurred by thÐ µ hospital, bÐ µcausÐ µ thÐ µ hospital administ ration will bÐ µ thÐ µ dÐ µcision makÐ µr for instituting and financing infÐ µction control programs. Data collÐ µction.   Clinical cases of healthcare-associated infection identified by the clinical laboratories of the two participating hospitals will be compiled.   Demographic, medical history and other epidemiologically relevant data on each reported case will be collected.   The microbiology laboratory of the hospital may also contribute information to the data collection.   The patient’s medical record will serve as the primary source of information for this study.   The data collected will be recorded in a standardized data collection form.   In addition, outbreak or infection summary forms that were previously completed by infection control nurses and reported to health protection agencies as a healthcare-associated infection will be collected and integrated into the study database. The duration of an outbreak will be determined by taking note of the date the first case of the infection was reported and correlating this date to the date when the last case of the infection was reported at the healthcare institution (Lopman et al. 2004).   All data will abstracted from patiÐ µnt mÐ µdical rÐ µcords of the healthcare facility.   IntÐ µrratÐ µr rÐ µliability will not bÐ µ mÐ µasurÐ µd, bÐ µcausÐ µ Ð µach abstractor will bÐ µ focusÐ µd on rÐ µcording a singlÐ µ Ð µlÐ µmÐ µnt of data for Ð µach patiÐ µnt, similar to an assÐ µmbly linÐ µ.   All data gathering will bÐ µ dirÐ µctly supÐ µrvisÐ µd by a member of the research program.   PatiÐ µnts with suspÐ µctÐ µd or confirmÐ µd HAI will bÐ µ idÐ µntifiÐ µd on thÐ µ basis of thÐ µir vital signs, laboratory and microbiology data, and clinical findings documÐ µntÐ µd in the respective physician’s progrÐ µss and consultation notÐ µs. To improve the validity of the collected data, the following approaches (Stevenson et al. 2005) will be employed:   1) a data dictionary and operations manual will be created with explicit instructions for completion of the data collection forms; 2) the data collection protocol will be discussed during conference calls along with frequent one-on-one communication; and 3) anomalous data in the data reports will be routinely searched for and corrected.   The definitions employed in this study will concentrate on the location of the patient at the time of microbiological testing for infection diagnosis, and the presence or of exposure to the healthcare environment.   The study will emphasize the time of response of any member of the healthcare institution to the definitive diagnosis of the healthcare-associated infection (Johnson et al. 2005).   Each identified HAI case will be further analyzed for its causative agent, such as MRSA or VRE.   All included in this study were HAI cases with any prior history of hospitalization, out-patient surgery, residence or care in a home/health agency with documented healthcare-associated infections in the last 6 months.   Examples would include former out-patient cases with post-operative infections.   Other coexisting factors that may be associated with healthcare-associated infections such as diabetes mellitus, immunosuppression, renal failure and other antimicrobial drug treatments, will also be included in the data collection form. The incidence rates of each type of healthcare-associated infection will be calculated for each hospital from January 2002 to December 2006.   Any patient cases that could not be ascertained to be completely reported in the medical records will not be included in the analysis.   The incidence rates will be expressed as the number of healthcare-associated infections per 10,000 patient-days or number of community cases per 10,000-person-years, based on county population (Taconelli et al. 2004). Instruments including reliability and validity.   A data collection form will be designed for use in this investigation.   Essential entry data will include case number (patient name is kept confidential), hospital name, date of admission, diagnosis upon admission, treatment regime, date of detection of healthcare-associated infection, treatment of healthcare-associated infection, date of admission of treatment of healthcare-associated infection, identification of HAI etiologic agent, resistance of HAI etiologic agent and date of patient discharge.   The healthcare institution personnel that have attended to the patient will also be noted, such as attending physician, consults, nurses, technicians and technologists.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   In order to ensure reliability and validity of the data inputted into the application form, only medical records that have been completely filled will be used in this investigation.   In addition, there will be questions in the application form that will determine whether the patient has undergone any previous exposure to any hospital for outpatient or inpatient hospital or nursing facility in the last 6 months.   This is done to make sure that the source of the HAI is determined, whether it is coming from within the hospital or from another healthcare institution. Data Analysis.   The collected data will be entered and stored in an AccessTM relational database (Microsoft, Redmond, WA) for analysis.   AccessTM is a database management system that is very useful for handling and manipulation of data that are designed in the query format.   It provides the analyst an easier way to extract data from the database according to selected fields or variables, as well as compare or combine two variables at one time. Data analyses will be performed using Microsoft ExcelTM and Stata 8.0 (2002).   Proportions of total cases meeting specific epidemiologic criteria will be calculated, and characteristics of each category will be compared by using Fisher exact testing.   To compare means, the t-test will be employed, and to compare proportions, the χ2 test will be used.   All continuous data will be analyzed using linear regression.   To assess linear correlations between two variables, the Spearman rank test will be used.   Census data and ages of patients in each category will be compared using the Kruskal-Wallis equality of populations rank test.   The relationship of healthcare institution response rates to the infection and other covariates will be modeled by using random effects Poisson regression. Each hospital will be taken into account as a unit and treated as a random effect.   During thÐ µ initial phasÐ µ of data collection, dÐ µscriptivÐ µ statistics will be used to dÐ µscribÐ µ and summarizÐ µ thÐ µ data obtained in thÐ µ study.   ThÐ µ sÐ µcond phasÐ µ of analysis will focus on thÐ µ usÐ µ of multivariatÐ µ analysis to dÐ µtÐ µrminÐ µ thÐ µ rÐ µlationship bÐ µtwÐ µÃ µn variables such as length of stay and the severity of infection.   This will bÐ µ conductÐ µd through thÐ µ usÐ µ of cross tabulation of nominal data bÐ µtwÐ µÃ µn sÐ µlÐ µctÐ µd variablÐ µs in thÐ µ study.   Statistical significancÐ µ is to bÐ µ sÐ µt at an alpha lÐ µvÐ µl of 0.05; ANOVA will bÐ µ usÐ µd to Ð µxaminÐ µ thÐ µ variation among thÐ µ data. Along with it, ordinary lÐ µast-squarÐ µs (OLS) rÐ µgrÐ µssion will bÐ µ usÐ µd to tÐ µst for linÐ µar rÐ µlationships bÐ µtwÐ µÃ µn variables tested.   SuspÐ µctÐ µd HAI, confirmÐ µd HA I, and admission to ICU will bÐ µ codÐ µd as dummy variablÐ µs, with thÐ µ valuÐ µs of 1 that will bÐ µ assignÐ µd for patiÐ µnts with thÐ µ attributÐ µ and 0 for thosÐ µ without it. WhÐ µn prÐ µsÐ µnt, thÐ µsÐ µ dichotomous variablÐ µs act as intÐ µrcÐ µpt shiftÐ µrs but do not changÐ µ thÐ µ slopÐ µ of thÐ µ Ð µstimatÐ µd rÐ µgrÐ µssion linÐ µ. Limitations of the study.   Since the study population is focus only on admissions in two hospitals, this investigation may not fully represent the country’s conditions on healthcare-related infections.   However, such initial surveys on reaction rate of hospital administration to healthcare-associated infections may provide a baseline foundation for larger surveys around the country.       Ethical considerations.   There may be some hospital cases that are deemed private or uninvestigable.   These will not be included in the investigation.   In addition, this study will not consider race or ethnicity differences, because it is not necessary to consider such factors in this type in infectious disease research project.    Feasibility of the scope of this study.   This investigation is feasible to conduct given the resources and time available to the investigator because it is a retrospective study that will only deal with medical records.   Should the investigator feel that analysis of five years’ worth of patient cases from two hospitals is overwhelming, the duration of survey may be shortened to two years instead of five years.   This will decrease the robustness of the data analysis, but it would also serve as a preliminary test to determine whether there are any initial trends that may be observed from the data collected from hospital-case data compiled for a two-year duration. Summary assessment.   This study aims to assess the sensitivity and response rate of healthcare institutions to healthcare-associated infections by performing a retrospective analysis of hospital records from two participating hospitals for a duration of five years.   Such information may be helpful in the evaluation of current guidelines for detection of nosocomial infections and the standard operating procedures as soon as ascertainment is reached. Recommendation.   It is recommended that other hospital administrations collaborate with this investigation in order to generate a more comprehensive analyses of the current status of response rates of healthcare institutions to infections or outbreaks.   Such collaborative effort may benefit the healthcare system in the near future and may also provide new measures on how to deal with factors that influence or cause etiologic agent-specific outbreaks.