京都大学 / 新制・課程博士 / 博士(医学) / 甲第23755号 / 医博第4801号 / 新制||医||1056(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 川上 浩司, 教授 小濱 和貴, 教授 平井 豊博 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

På Sveriges akutmottagningar ses att vistelsetiden ökar och att äldre över 65 år är de som står för nära hälften av alla akutbesök och mer än hälften av all sammanlagd vårdtid. Vistelsetiden inom sjukvården beskrivs med två begrepp, LOS som står för den totala vistelsetiden inom sjukhuset och ED LOS som beskriver vistelsetiden på akutmottagningen. Förlängd ED LOS och LOS drabbar äldre genom ökad förekomst av vårdskador och dödlighet. Skörhet är ett begrepp som används för att beskriva äldre som bedöms ha ökad risk att drabbas av sådana negativa konsekvenser. Sjuksköterskan på akutmottagningen har en nyckelfunktion inom patientsäkerhetsarbete och en viktig roll i att effektivisera patientflödet.  Syftet var att beskriva sjuksköterskeinitierade interventioner för sköra äldre på akutmottagning genom att undersöka vad som var gemensamt i interventionerna samt deras effekt på ED LOS och LOS.  En litteraturöversikt användes som metod. Datainsamlingen genomfördes via databassökningarna i PubMed och CINAHL. Femton vetenskapliga artiklar som beskrev sjuksköterskeinitierade interventioner som utfördes på akutmottagningar och som mätte ED LOS och LOS inkluderades i resultatet. Artiklarna kvalitetsgranskades och analyserades genom en integrerad analys.  I resultatet framkom tre huvudkategorier med sju tillhörande underkategorier som beskrev gemensamma fynd i interventionerna. Huvudkategorierna var kunskapens betydelse för interventionen, samverkan för den sköra äldre och identifiering, bedömning och behandling av sköra äldre. ED LOS och LOS presenterades i relation till huvudkategorier och underkategorier. ED LOS minskade i nio interventioner, ökade i två och hade ingen signifikant skillnad i två. LOS hade ingen signifikant skillnad i fem interventioner och minskade i tre.  Slutsatsen var att specialistsjuksköterskor har en viktig roll i att utveckla, implementera och leda interventioner för sköra äldre samt att samarbete mellan professioner och över organisationsgränser och införande av snabbspår var viktiga gemensamma faktorer i interventioner som minskade ED LOS och i viss mån LOS.

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The cost and duration of cardiovascular care was studied for 4,804 episodes of hospitalization in patients between 45 and 64 years of age. Men were more likely than women to be treated in urban medical centers for shorter, more expensive hospital care; women were more likely to be treated in rural hospitals for longer, less expensive care. Cost of treatment per day was not dependent on the type of insurance, but Medicaid claims (which represent low income patients) were associated with greater lengths of stay.

Urinary tract infections (UTI) in neonates are caused by many types of risk factors such as increased length of maternal labor, physiologic maternal conditions, prematurity, and decreased birth weight. Identification of potential risk factors for UTI in neonates can lead to rapid assessment and early interventions to treat urinary infection in the neonate before it transitions to a severe or life-threatening condition, such as a kidney infection or septicemia. The primary purpose of this literature review was to examine risk factors predisposing neonates to UTI. The secondary purpose was to identify if length of time to drug therapy used to treat UTI in neonates decreased complications and recurrence in the preterm infant. A comprehensive literature review was performed using research articles available from 2007 to 2021 regarding the factors influencing the occurrence of urinary tract infections in neonates. Databases used to search for articles include EBSCOhost databases, Medical Literature On-Line (Medline), Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Google Scholar. Searches used a combination of the following terms: ‘UTI’, OR ‘urinary tract infection’, AND ‘neonates’, OR ‘infants’, ‘risk factors’. Of the articles reviewed, 15 met the inclusion criteria and answered the research questions. Two studies showed circumcision in male infants increases the risk of urinary tract infection in infants. Two studies revealed vesicourethral reflux in female infants compared to male infants increases the risk of UTIs. One article suggested women with longer labor (>24 hours) from onset had an increased likelihood of the newborn having a UTI within the first week of life. Preliminary data suggests there are significant precursors and risk factors that can be identified to diagnosis UTIs early and having them treated promptly. All the reviewed articles focused on collection of urine samples within hours of birth and physiologic findings of a UTI can decrease the length of stay and costs related to infection treatment. Antibiotic therapy being administered empirically due to rapid assessment of risk factors for UTI in the neonate decreases time to treatment by three to five days, which improves health outcomes. Rapid assessment and diagnosis of UTI is of value for preventable measures to be ordered sooner to avoid repeat and resistant UTIs in the neonate.

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In 2008, Sweden changed its labor migration legislation and allowed for labor migrants from non EU/EEA countries to migrate to Sweden, which had been heavily restricted since the 1970s. This shift in labor migration policy is mirrored in Swedish integration policy where the focus in recent years has been on labor market integration. This thesis aims to investigate the sociocultural integration of migrants who are employed and, in the Swedish context, assumed to be integrated. In addition, sociocultural integration is related to employment and length of stay. Sociocultural integration is measured by three indicators: knowledge of Swedish language, having Swedish friends, and membership in organizations. The data was collected through sixteen semi-structured interviews of highly educated migrants with employment in Sweden and analyzed using four integration theories.The study reveals that employed migrants are only partially socioculturally integrated. Respondents presented low levels of Swedish-language knowledge, which can be explained by their short stay in the country as well having international workplaces where mostly English is spoken. However, these workplaces also offer respondents opportunities to meet natives and most respondents met their Swedish friends through work. There is a need for further studies of integration, in particular those that would explore multiple dimensions of integration and incorporate migrants who are already economically integrated.

Thesis advisor: Monica O'Reilly-Jacob / Background: Emergency department crowding (EDC) is a major issue affecting hospitals in the United States and has devastating consequences, including an increased risk of patient mortality. Solutions to address EDC are traditionally focused on adding resources, including increased nurse staffing ratios. However, these solutions largely ignore the value of the experience and expertise that each nurse possesses and how those attributes can impact patient outcomes. This dissertation uses Benner’s Novice to Expert theory of professional development to describe how individual emergency nurse expertise influences patient length of stay in the emergency department and how it can be part of the strategy in addressing EDC.Purpose: The purpose of this program of research was to identify, articulate, and demonstrate a new approach to emergency nurse performance evaluation that integrates patient outcome data and emergency nurse characteristics. Methods: First, in a scoping review, we explored the different approaches to measuring nurse performance using patient outcome data and identified common themes. Second, a concept analysis introduced Emergency Nurse Efficiency as a novel framework to understand how emergency nurses can be evaluated using patient outcome data. Finally, a retrospective correlational study established the association between nurse expertise and emergency patient length of stay. Results: In Chapter Two of this dissertation, the researchers conducted a scoping review of nurse performance metrics and identified twelve articles for inclusion. We identified three themes: the emerging nature of these metrics in the literature, variability in their applications, and performance implications. We further described an opportunity for future researchers to work with nurse leaders and staff nurses to optimize these metrics. In Chapter Three, we performed a concept analysis to introduce a novel metric, called Emergency Nurse Efficiency, that is a measurable attribute that changes as experience is gained and incorporates the positive impact of an individual nurse during a given time while subtracting the negative. Using this measurement to evaluate ED nurse performance could guide staff development, education, and performance improvement initiatives. In Chapter Four, we performed a retrospective correlational analysis and administered an online survey to describe the relationship between individual emergency nurses, and their respective level of expertise, and their patients’ ED LOS. We found that, when accounting for patient-level variables and the influence of the ED physicians, emergency nurses are a statistically significant predictor of their patients’ ED LOS. A higher level of clinical expertise among emergency likely produces a lower ED LOS for their patients, and nurse leaders should seek to better understand these metrics for professional development and quality improvement activities. Conclusions: This dissertation made substantial knowledge contributions to the literature regarding the evaluation of individual emergency nurses and the influence that they have on patient outcomes. It established, first, that the measurement of individual nurse performance is varied and inconsistent; second, that considering emergency nursing as a team activity similar to professional sports results in a conceptual framework that can evaluate individual performance within a group context; and, third, that there is a relationship between the individual emergency nurse and their patients’ ED LOS, and that relationship can be further understood within Benner’s Novice to Expert theoretical model. We recommend that nurse leaders use these data as part of their strategy to decrease EDC. / Thesis (PhD) — Boston College, 2023. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第25157号 / 医博第5043号 / 京都大学大学院医学研究科医学専攻 / (主査)教授 石見 拓, 教授 西浦 博, 教授 江木 盛時 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM