The Institute of Medicine identified that 98,000 deaths occur in hospitals each year due to poor decision-making. The need for better understanding of decision-making in patient care is evident. The purpose of this study is to explore nurses' perceptions of clinical decision-making for a patient who experienced a clinical event. The overarching framework for this research is the Effective Nurse to Nurse Communication framework which uses clinical events, or sudden changes in patient condition, to explore nurse communication between nurses who respond to a clinical event and nurses who receive report from the responding nurse about the clinical event. Naturalistic Decision Making is the framework used to explore the decision-making factors used by experienced decision makers in real world conditions. These frameworks provided the basis for data collection, interview question development, and facilitated data analysis. Twenty nurses in an urban acute care hospital were interviewed at their workplace about a patient who had experienced a sudden change in condition in the previous 24 hours. These interviews were transcribed and analyzed using content analysis. Categories that emerged were: Awareness of Patient Status, Nursing Roles (outside of specific patient care), Goals, Education / Certification / Hospital Training to support decision-making, Experience and Decision-Making, Time Pressure, Teamwork / Support from Staff, Resources, Following Established Routine. Patient Education, and Consideration of Options to Meet Goals. Further analysis indicates that elements of decision-making differ between responding and receiving nurses and based on experience level of the nurse. Strengths, limitations, and suggestions for future research are presented.

Abstract Objectives: This research project was undertaken to review two commonly used screening instruments for the elderly who attend at hospital emergency departments in Ontario. These instruments were then contrasted with a new potential screening instrument made up of items drawn from the Minimum Data Set-Acute Care instrument (MDS-AC Version 1_CAN). The hypothesized outcome was better specificity and sensitivity utilizing the newly prepared instrument in predicting at an earlier point if an elderly emergency department patient would become an alternate level of care (ALC) patient. The ability of the screener to predict negative outcomes (delirium, longer length of stay) was also analyzed. Methods: One dataset from a previous International Resident Assessment Instrument (interRAI) organization study in southern Ontario completed in 2000 was utilized to inform this research. Each of the commonly used screening instruments was crosswalked to the MDS-AC items, then both univariate and bivariate analyses were completed. Three research questions were then posed. By testing various logistic regression models, the research looked to establish whether the newly developed instrument would be able to perform comparably to the other two currently-used instruments, and whether it would be more effective in predicting ALC status and particular adverse patient outcomes. Results: The newly-developed instrument was found to perform more accurately. While several variables were tested, a core number were found to be more strongly predictive of future need for ALC status. Conclusions: Future research in this area is recommended.

Introduction: Acute Care Surgery (ACS) is a new model of emergency general surgery care developed to provide prompt, comprehensive, and evidence-based care to acutely ill non-trauma surgical patients. Our objective was to determine the impact of implementing ACS on efficiency of care (EOC) and patient outcomes. Methods: A retrospective review was performed for patients with acute appendicitis (AA) and biliary tract disease (BTD). EOC measures and patient outcomes were compared over two time periods: pre-ACS (2007) and ACS (2011). Results: n=1,229 patients were included in this study; n=507 (pre-ACS), and n=722 (ACS). Surgical response times and acquisition of imaging were significantly faster with ACS. Time to OR and total LOS were similar between cohorts. Similar rates of daytime operating were present. With ACS and AA, there were more perforations, more ORs were performed at night and patients were readmitted more frequently. Conclusions: Increased volumes of patients were seen with ACS, but surgical assessments and imaging were significantly faster. Inpatient EOC measures were unchanged with ACS; outcomes for AA were worse. / October 2015

Abstract Objectives: This research project was undertaken to review two commonly used screening instruments for the elderly who attend at hospital emergency departments in Ontario. These instruments were then contrasted with a new potential screening instrument made up of items drawn from the Minimum Data Set-Acute Care instrument (MDS-AC Version 1_CAN). The hypothesized outcome was better specificity and sensitivity utilizing the newly prepared instrument in predicting at an earlier point if an elderly emergency department patient would become an alternate level of care (ALC) patient. The ability of the screener to predict negative outcomes (delirium, longer length of stay) was also analyzed. Methods: One dataset from a previous International Resident Assessment Instrument (interRAI) organization study in southern Ontario completed in 2000 was utilized to inform this research. Each of the commonly used screening instruments was crosswalked to the MDS-AC items, then both univariate and bivariate analyses were completed. Three research questions were then posed. By testing various logistic regression models, the research looked to establish whether the newly developed instrument would be able to perform comparably to the other two currently-used instruments, and whether it would be more effective in predicting ALC status and particular adverse patient outcomes. Results: The newly-developed instrument was found to perform more accurately. While several variables were tested, a core number were found to be more strongly predictive of future need for ALC status. Conclusions: Future research in this area is recommended.

The published literature indicates that large information system implementations are often expensive failures with costs to human safety largely because of missing or corrupt information. This has generated the overall research question of “What do Key Informants think about Information Quality in Acute Care?” This dissertation research examined information quality using a Grounded Theory analytic method for coding and analyzing semi structured interview responses from ten clinical (nurses, physicians, pharmacist) and ten non-clinical (IT support) interviewees in several public sector health organizations across Canada. The semi structured interview questions focused on five key areas: information quality, acute care setting, information systems, risk (as a function of poor information quality) and patient safety. A key finding from the interview data is that information is missing and unstable within the two key health care information systems: the paper chart, the main repository of narrative unstructured data, and the electronic health record system, of structured data. The interviewees mentioned pressure to information standardization such as fixed patient identity information anchoring patient data in the rest of the patient record. However, there is resistance to standardizing other information because the users, nurses and physicians, resist fettering in order to be able to tell the patient’s story in narrative unstructured data form. A descriptive socio-technical model, the Systems Engineering Initiative for Patient Safety (SEIPS) Model that organizes elements for analysis under the headings of person, task, technology and tools, organization, external environment and patient outcomes, was considered for further discussion in the context of the study. The SEIPS Model analysis also helps to identify gaps in the Model including what missing and uncertain information might mean. Key points from this discussion include how the information system maps to the real world, the patient, and to the user’s perception of the real world. This mapping can never be totally accurate and complete so gaps exist. The discussion of information and information flow lead to enhancements of the SEIPS Model, placing information and information quality in its rightful place as a “glue” for the acute care system. This is an important contribution to knowledge that can lead to future research so there can be a better fit between the real world, information, information systems and people to provide safer care. / Graduate

Background: With the increasing older adult population, new graduate nurses will be providing care for patients with dementia more frequently and should be supported to care for this population during their transition period. Purpose: The purpose of this thesis was to explore the experiences of new graduate nurses providing care for patients with dementia in acute care environments. Methods: An interpretive descriptive qualitative study explored eleven Ontario new graduate nurses’ experiences providing dementia care in acute care environments. A thematic analysis was conducted. Findings: The thematic analysis resulted in three themes and several sub-themes: building of vision and values, clash of vision and values, and “make do with what you have”. Discussion and Conclusion: Facilitators to providing dementia care in acute care were supportive colleagues and early exposure to dementia care. The barriers identified were similar to the barriers experienced by nurses in the literature.

Over 4 million avoidable hospital admissions result from medication errors (IMS Insitute for Healthcare Informatics, 2013). Human error accounts for 80% of all medical errors (Palmieri, DeLucia, Peterson, Ott, & Green, 2008). Medication administration is a complex process. It is important to understand the cognitive load (CL) of Registered Nurses (RNs) working in an electronic health record environment to identify the risk factors of medication errors. The purpose of this study is to investigate the factors that influence the CL of RNs during medication administration who are working in an electronic health record environment. Simulated medication administration scenarios with varying degrees of multi-tasking were completed with 30 participants. When RNs multi-task during medication administration their CL increases. Furthermore, RNs who have poor sleep quality cannot process high-level tasks as well as those RNs who report a good sleep quality. Future work can limit EEG lead placement to the frontal channels of the EEG. Furthermore, replication of this study with a larger sample and a broader range of competing tasks is indicated.

Class of 2014 Abstract / Specific Aims: Clostridium difficile associated diarrhea (CDAD) frequently occurs in patients exposed to broad-spectrum antibiotics which can result in a life threatening illness. The role of probiotics in the prevention of CDAD is not well established and many medical centers across the United States are opting to remove probiotics from common CDAD prophylaxis. We aim to evaluate the efficacy of lactobacillus probiotics during the use of broad-spectrum antibiotic therapy in the acute care setting for the prophylaxis of CDAD at Kindred Hospital. Methods: We performed a single center, retrospective data analysis efficacy trial of inpatients receiving beta-lactam, fluoroquinolone or clindamycin antibiotics from the Kindred Hospital database. Two study groups will be compared: patients who received lactobacillus probiotic therapy based on protocol since May 2011 and patients who did not receive probiotic therapy. The presence or absence of CDAD will be used to evaluate probiotic efficacy. Main Results: Of the ### patients screened, ## were assigned to the treatment group and ## were assigned to the non-treatment group, a total of ## patients were analyzed for the primary endpoint. CDAD occurred in ## patients (xx%) receiving probiotic therapy while CDAD occurred in ## patients (xx%) not receiving probiotic therapy (relative risk [RR]: xx.x; p=0.xxx). Conclusion: [Anticipated] We identified no statistically significant evidence that the use of lactobacillus was effective in the prevention of CDAD. Further knowledge of the pathophysiology of CDAD and proper antibiotic use is needed for future studies.

At present, the promotion of health in significant changes. In my work I try to find out how the financing of health care facilities, respectively. hospitals in the Czech Republic, especially in the Pardubice region. The work shows how to manage individual county hospital and the problems they face. To fulfill its objective, it is used the most recent literature, legislation and financial statements hospitals. The main contribution of this work is a complete analysis of five acute care hospitals in the Region, as yet arisen document, which would thus comprehensively evaluate the economic situation of hospital care in this region. Based on the findings is then in the final part of the thesis evaluates the real state management of five acute care hospitals. Outlines the major problems in hospitals and nejich possible solution.

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