Introduction: Death occurs frequently in emergency departments (EDs). Obstacles present in EDs can make providing end-of-life (EOL) care stressful and challenging for emergency nurses. Although death is common in EDs, there is a paucity of research regarding ED design as an obstacle to EOL care. The purpose of this study was to identify emergency nurses experiences and recommendations regarding ways ED designs negatively or positively impacted EOL care for dying patients and their families. Methods: At 25-item questionnaire regarding ED design and EOL care was sent to a geographically dispersed, national random sample of 500 emergency nurses. Inclusion criteria were nurses who could read English, worked in an emergency department, and had cared for at least one patient at the EOL. Responses were individually reviewed and coded by the research team.Results: Major obstacles relating to ED design identified by emergency nurses included (1) many issues related to limited space, (2) poor department layout and design features, and (3) the lack of privacy. Despite EDs being a challenging place to provide EOL care, positive ED design characteristics impacted EOL care for dying patients and families.Discussion: Emergency nurses understand the need for family presence during resuscitation, for secure body stowage areas, and for more resuscitation rooms so that families have time to grieve before being removed due to the immediate need for a second trauma patient and family. Nurses can evaluate existing facilities and identify areas where potential change and remodeling would improve patient care, increase patient privacy, or further utilize space. Conclusion: Understanding ED designs impact on EOL care is crucial. Modifications to ED layout and design may be challenging; however, improvements to space, layout, and privacy need to be considered when planning new EDs or remodeling existing departments. Further research is required to determine the impact of ED design on EOL care.

This study examines factors that influence the intent to use and actual use of decision support software (DSS) technology by emergency management officials to facilitate disaster response management. The unified theory of acceptance and use of technology popularized by scholars from the field of information sciences (IS) for the private sector is adapted and extended to examine technology use in the public sector, specifically by emergency managers. An e-survey was sent to 1, 452 city and county emergency management officials from FEMA region VI and complete responses obtained from 194 were analyzed. Findings suggest that social influence is the strongest predictor of intent to use DSS technology by emergency managers, unlike private sector studies where performance expectancy was the strongest predictor. Additionally, effort expectancy, collaboration, social vulnerability, professionalism, performance expectancy, and gender explained 40 percent of their intent to use DSS technology. Factors explaining actual use of technology were intent to use technology, having an in house GIS specialist, and age of the emergency manager. This research successfully closes the gap in IS and disaster literature by being the first to focus on factors influencing technology use by emergency managers for decision making in disaster response. It underscores the importance of collaboration not only for post-disaster activities but also as a precursor to better disaster preparedness planning that calls for information sharing and technology acceptance and adoption across partnering jurisdictions.

In order to more fully inform moves toward equity in emergency management (EM), this research seeks to describe a general landscape of professional Tribal EM, and in particular, to examine how Tribal emergency managers and Tribal Nations are situated in relation to the EM enterprise (EME), and how they are doing resilience in their Tribal Nations. The findings presented in this dissertation reflect efforts to explore and document Tribal emergency managers' descriptions of their work and their perceptions about its context as they seek to do resilience in their Tribes. Specifically, qualitative interviews were conducted with Tribal emergency managers whose Tribal Nations span the United States. Findings indicate that there is significant variation among Tribal nations in terms of EM structures and capacities; Tribal emergency managers engage in a wide array of activities to promote resilience in their communities; and Tribal EM is becoming increasingly professionalized. Importantly, however, the research also uncovered a paradox in which Tribal emergency managers, both implicitly and explicitly excluded from the EME in many ways, find themselves doing resilience in the context of an increasingly popular disaster resilience paradigm that both increasingly shifts the burden of resilience to the local level, and expands the range of tasks associated with successful resilience processes. The dissertation concludes by discussing conceptual and practical implications of the research as well as directions for future research in this area.

Sepsis is a complicated disorder in which an infection has reached the bloodstream and caused a cascade of events that in time will lead to death. Interventions aimed at identifying sepsis early in its progression are imperative to stopping the process. The purpose of this study is to examine the current state of the literature regarding sepsis screening tools utilized by emergency medical services. A literature review exploring the various tools in place was conducted to see their value in predicting sepsis and secondary what the initiation of a sepsis alert has on the patients’ outcome. Results found included that sepsis screening tools when in place decrease time to identification, decrease time to antibiotics, increase amount of fluid administration, and overall reduce hospital stay and mortality rate. With these findings educational training for EMS providers and the introduction of generalized protocols are of the upmost importance. Further research is needed to be done to create a consistent tool to be used by all EMS agencies that has a validated predictive value of sepsis.

The opinions and expertise of disabled people are often absent from emergency preparedness planning. As a result, when emergencies occur disabled people’s needs may go unmet. While there have been recent efforts to acknowledge the need for disability inclusive planning processes (in, for example, the development of a Disability Inclusive Disaster Risk Reduction framework), more research is needed to understand how efforts to include the perspectives and experiences of disabled people work (or do not work) in practice. In this research, I examine the development of a disability-inclusive emergency preparedness plan in Ontario, Canada. I use semi-structured interviews with key informants from the provincial government and disability organizations to unpack the planning and consultation process. The analysis indicates that while the plan represents an important attempt to include disabled people in emergency preparedness planning, it falls short in a number of ways not least because it rests on a narrow conception of disability as physical limitation. In particular, people with intellectual disabilities are absent from the planning process and final plan, a fact that reflects their broader marginalization within society. I draw on interviews with a small sample of self-advocates living with intellectual disabilities to identify how the plan could be revised to recognize the views and experiences of this population. / Thesis / Master of Arts (MA)

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Yes / The most common route to a hospital bed in an emergency is via an emergency department (ED). Many recent initiatives and interventions have the objective of reducing the number of unnecessary emergency admissions. We aimed to assess whether ED admission thresholds had changed over time taking account of the casemix of patients arriving at ED. Methods: We conducted a retrospective cross-sectional analysis of more than 20 million attendances at 47 consultant-led emergency departments in England between April 2010 and March 2015. We used mixed- effects logistic regression to estimate the odds of a patient being admitted to hospital and the impact of a range of potential explanatory variables. Models were developed and validated for four attendance subgroups : ambulance-conveyed children; walk-in children; ambulance-conveyed adults; and walk-in adults. Results: 23.8% of attendances were for children aged under 18 years, 49.7% were female and 30.0% were conveyed by ambulance. The number of ED attendances increased by 1.8% per annum between April 2010 – March 2011 (year 1) and April 2014 –March 2015 (year 5). The proportion of these attendances that were admitted to hospital changed little between year 1 (27.0%) and year 5 (27.5%). However, after adjusting for patient and attendance characteristics the odds of admission over the five year period had reduced by: 15.2% (95% CI 13.4% - 17.0%) for ambulance-conveyed children; 22.6% (95% CI 21.7%-23.5%) for walk-in children; 20.9% (95% CI 4%-21.5%) for ambulance conveyed adults; and 22.9% (95% CI 22.4%-23.5%) for walk-in adults. Conclusions: The casemix-adjusted odds of admission via ED to NHS hospitals in England have decreased since April 2010. EDs are admitting a similar proportion of patients to hospital despite increases in the complexity and acuity of presenting patients. Without these threshold changes, the number of emergency admissions would have been 11.9% higher than was the case in year 5.

Registered nurse (RN) insufficiency is both a major contributor to and effect of emergency department overcrowding (EDOC) in the United States and is implicated in increased patient mortality, ED wait times, and general congestion of the healthcare system. Licensed paramedics represent a viable solution to this crisis given their extensive training in emergency care by serving as RN adjuncts and alternatives in the ED setting. Paramedics utilize high-level clinical judgment and patient assessment skills to form detailed clinical impressions and employ a wide range of therapies to initiate treatment. Although they less frequently possess a college degree than their RN counterparts, paramedics complete a comparable study of medical science principles, patient assessment, and pathophysiology, and devote significantly more time to critical care and emergency medicine than RNs. Implementation of paramedics in U.S. EDs in the 1980s and 1990s highlighted their manual and technical skill prowess as well as their ability to rapidly assess emergency situations, including their unexpectedly widespread use in pediatric EDs. Modern implementation includes expansion of the psychomotor skills available to ED-based paramedics, with emphasis on medication administration and emergency procedures, but there is a significant lack of research into paramedic assessment and triage skills in the ED. Barriers to further implementation of ED paramedics include resistance from nursing advocacy organizations, regulatory and legal challenges, and public opinion and attitudes of nurses and paramedics. Nursing advocacy groups have historically opposed paramedic integration, fearing job encroachment and increased autonomy for non-nursing healthcare professionals. Regulatory challenges involve certification vs licensure discrepancies, limitations on paramedic scope of practice, and the wide-reaching effects of state Nurse Practice Acts. Societal resistance, cultural factors, and attitudes within the nursing and paramedic communities also impede further ED paramedic implementation. Practice recommendations are proposed, including the development of standardized ED orientation programs for paramedics, and redefining the minimum education for paramedics at the associate degree level. Legislative recommendations involve eliminating statutory restrictions on paramedic practice, reevaluating language in state Nurse Practice Acts, and clarifying the legal relationship between RNs and ED paramedics. The limitations of this literature-based thesis include a lack of large-scale studies, regional variability, and the absence of empirical examination of paramedic integration in reducing ED overcrowding. Future suggestions for study include randomized controlled trials comparing ED patient outcomes between RNs and paramedics, interrater reliability studies on assessment and triage skills, and comparisons of scope of practice and education between paramedics in different countries.

published_or_final_version / Community Medicine / Master / Master of Public Health