published_or_final_version / Community Medicine / Doctoral / Doctor of Philosophy

This thesis deals with the problem of locating emergency ambulances in an urban area. We developed a simulation model to analyze possible improvements in ambulance service. A new point-to-point travel time model is introduced in our simulation. Validating the model proved to be a difficult task and is discussed in detail. Our model has been applied to the Tucson Emergency Medical Service system.

This thesis deals with the problem of locating emergency vehicles in an urban area. An optimization model is formulated that extends previous work by allowing stochastic travel times, unequal vehicle utilizations, and backup service. The heart of the model is a procedure similar to the Hypercube approximation model. Ten pair-wise interchange heuristics are developed and tested on 240 test problems. Demand and service time components of the test data have been generated using characteristics of the Tucson Emergency Medical System. Geographical components of the test data have been generated using actual city shapes as models. It is believed that these test problems are more indicative of actual emergency vehicle location problems than those previously presented in the literature.

<p><em>Introduction: </em>In Sweden the definition of <em>ambulance nursing </em>is the examination and treatment of sick or injured people done by ambulance nurses during transport.  This means not only focus on the illness or injury but also the human being treated. The paramedic service must be based on the presumption that the medical needs of the patients are guaranteed, and that the expectations and demands of the public are satisfied. Competence and availability are basic terms for a well-functional paramedic service. There is a lot of pressure put on the people working with pre-hospital nursing. One mistake can lead to serious consequences for the patient. <em>Purpose: </em>The purpose of this study is describing patient’s experience of pre-hospital nursing. <em>Method:</em> The study is based on ten scientific articles. The articles were found on the internet by searching in the databases Academic Search Elite, Cinahl and MedLine. <em>Results:</em> The following themes have been identified: a feeling of uncertainty of the patient – how ill am I?, ambulance or own car?,  the patients worry about if the ambulance will arrive in time, voluntary self-surrender, patients experience of the competence of the staff, lack of understanding that an ambulance is more than a transport service. <em>Discussion:</em> Since the study is based on such a limited material it's not reasonable to draw any extensive conclusions. Still the results are so unanimous so we think that they are well worth to take into consideration.</p> / <p><em>Introduktion:</em> I Sverige definieras ambulanssjukvård med undersökningen och behandlingen av sjuka eller skadade människor, vilket utförs av ambulanspersonal i samband med transport. Ambulanssjukvården måste bygga på förutsättningen att patientens medicinska behov säkerställs och att allmänhetens förväntningar och krav blir tillgodosedda. Kompetens och tillgänglighet är grundläggande begrepp för en väl fungerande ambulanssjukvård. Det ställs stora krav på personalen inom den akuta prehospitala sjukvården. Ett enda felaktiga beslut kan få svåra konsekvenser för patienten. <em>Syfte:</em> Syftet med studien är att belysa patienters upplevelser av prehospital sjukvård. <em>Metod:</em> Litterturstudie vars resultat baseras på tio vetenskapliga artiklar publicerade 2003-2008. Litteratursökningen utfördes med de elektroniska databaserna Academic Serch Elite, CINAHL och MedLine<em>. Resultat:</em> De rubriker som identifierades var: en känsla av osäkerhet hos patienten, hur sjuk är jag?, ambulans eller egen bil?, oro hos patienten, när kommer ambulansen?, frivilligt "självöverlämnande", patienters upplevelse av personalens kompetens, och brist på insikt om att ambulans är mer än en transportservice. <em>Diskussion:</em> Att, utifrån ett begränsat material som det vi har arbetat med, dra några långtgående slutsatser är inte rimligt. Vi anser dock att samstämmigheten i resultatet är så god att vi vill klassa resultatet som väl värt att ta i beaktande.</p><p>                   </p> / Presentation är gjord via webben.

Prehospital care has developed dramatically the last decades with the implementation of new devices and educational concepts. Clinical decisions and treatments have moved out from the hospitals to the prehospital setting. In Sweden this has been accompanied by an increase in the level of competence, i.e. by introducing nurses in the ambulances. With some exceptions the scientific support for these changes is poor. This thesis deals with such changes in three different subsets of prehospital care: Cardiopulmonary resuscitation (CPR), the stroke chain of survival and trauma care. We assessed the performance of ambulance crews during CPR, using a mechanical compression device, as compared to CPR using manual compressions. There was a strikingly poor quality of compressions using the mechanical device compared to CPR with manual compressions. The result calls for caution when implementing a chest compression device in clinical practice and reinforce the importance of randomised controlled trials to evaluate new interventions. Careful attention should be given to the assurance of correct application of the device. Further implementation without evaluation of the quality of mechanical compressions in a clinical setting is discouraged. Among patients with a prehospital suspicion of stroke we analysed the ambulance nurses’ ability to select the correct patient subset eligible for a CT scan as a preparation for potential thrombolysis. The results do not support an implementation of a bypass of the emergency department, using ambulance nurse competence to select patients eligible and suitable for a CT scan without a preceding assessment by a physician. The association between the Prehospital Trauma Life Support (PHTLS) course and the outcome in victims of trauma was analysed in two observational studies. A study covering one county gave some support for a protective effect from PHTLS, but the estimate had a low precision. A nationwide study, covering all of Sweden, could not confirm those results. Although there was a reduction in mortality over time coinciding with the implementation of PHTLS, it did not appear to be associated with the implementation of PHTLS. Thus, we could not detect any clear beneficial impact of the PHTLS course on the outcome of trauma patients.

Study objectives: Examine ambulance personnel’s perceptions of skills / training and knowledge with regards to the existing mechanical / manual compressions and frequency of training during a work shift. Do ambulance personnel think that mechanical compressions increase survival? Are there concerns that the device could damage the patient? Design: A cross-sectional study, quantitative approach with qualitative elements was conducted. Methods: Questionnaire form, which was answered by 44 ambulance personnel in an ambulance organisation in Sweden. Participants were on a scale of 1-5 to select how they agree with the claims of the study form and also submit their own comments. The questions were compiled with SPSS 17.0. A content analysis was conducted of participants' comments. Results: Ambulance personnel believe that practice is necessary, but that in general this training is not carried out frequently enough. The training is not prioritised. Colleagues are overwhelmingly positive when spontaneous training is initiated. Better procedures and training materials mentioned as a factor strengthening conditions. It is considered equally important to have good knowledge of the performance of manual chest compressions, not relying solely on the mechanical ones. No one expressed any immediate concerns that mechanical chest compressions could cause damages, but stated that mechanical chest compressions do make a difference in a positive way in comparison to the manual ones. Conclusion: Exercise is not prioritized. Exercise routines should be reviewed. Availability of training material and its quality can be optimized. There is a need to identify attitudes to exercise and is important to find ways to create motivation and practice pleasure.

Introduction: In Sweden the definition of ambulance nursing is the examination and treatment of sick or injured people done by ambulance nurses during transport.  This means not only focus on the illness or injury but also the human being treated. The paramedic service must be based on the presumption that the medical needs of the patients are guaranteed, and that the expectations and demands of the public are satisfied. Competence and availability are basic terms for a well-functional paramedic service. There is a lot of pressure put on the people working with pre-hospital nursing. One mistake can lead to serious consequences for the patient. Purpose: The purpose of this study is describing patient’s experience of pre-hospital nursing. Method: The study is based on ten scientific articles. The articles were found on the internet by searching in the databases Academic Search Elite, Cinahl and MedLine. Results: The following themes have been identified: a feeling of uncertainty of the patient – how ill am I?, ambulance or own car?,  the patients worry about if the ambulance will arrive in time, voluntary self-surrender, patients experience of the competence of the staff, lack of understanding that an ambulance is more than a transport service. Discussion: Since the study is based on such a limited material it's not reasonable to draw any extensive conclusions. Still the results are so unanimous so we think that they are well worth to take into consideration. / Introduktion: I Sverige definieras ambulanssjukvård med undersökningen och behandlingen av sjuka eller skadade människor, vilket utförs av ambulanspersonal i samband med transport. Ambulanssjukvården måste bygga på förutsättningen att patientens medicinska behov säkerställs och att allmänhetens förväntningar och krav blir tillgodosedda. Kompetens och tillgänglighet är grundläggande begrepp för en väl fungerande ambulanssjukvård. Det ställs stora krav på personalen inom den akuta prehospitala sjukvården. Ett enda felaktiga beslut kan få svåra konsekvenser för patienten. Syfte: Syftet med studien är att belysa patienters upplevelser av prehospital sjukvård. Metod: Litterturstudie vars resultat baseras på tio vetenskapliga artiklar publicerade 2003-2008. Litteratursökningen utfördes med de elektroniska databaserna Academic Serch Elite, CINAHL och MedLine. Resultat: De rubriker som identifierades var: en känsla av osäkerhet hos patienten, hur sjuk är jag?, ambulans eller egen bil?, oro hos patienten, när kommer ambulansen?, frivilligt "självöverlämnande", patienters upplevelse av personalens kompetens, och brist på insikt om att ambulans är mer än en transportservice. Diskussion: Att, utifrån ett begränsat material som det vi har arbetat med, dra några långtgående slutsatser är inte rimligt. Vi anser dock att samstämmigheten i resultatet är så god att vi vill klassa resultatet som väl värt att ta i beaktande. / Presentation är gjord via webben.

published_or_final_version / Politics and Public Administration / Master / Master of Public Administration

Sammanfattning Bakgrund; Inom ambulansyrket utsätts personalen dagligen för tunga lyft, ofta i icke ergonomiska arbetsställningar samt i många fall under tidspress. Dessutom arbetar ambulanspersonal i regel skift och ibland hela dygn vilket medför en rubbad dygnsrytm. Syfte; Att beskriva hur yrkesutförandet påverkar den fysiska hälsan hos ambulanspersonalen, samt att beskriva vilken urvalsmetod som använts i valda artiklar. Metod; Litteraturstudien har en deskriptiv design och består av tolv vetenskapliga artiklar hämtade från databaserna Cinahl och Scopus. I tio av artiklarna har en kvantitativ ansats använts och de andra två består av en mixad ansats. Artiklarna har granskats utifrån likheter. I den metodologiska aspekten urvalsmetod har skillnader och likheter granskats. Resultat; Resultatet visade att ambulanspersonal i högre utsträckning än normgrupper lider av muskuloskeletala besvär. Vilket kan relateras till hög fysisk belastning samt icke ergonomiska arbetsställningar. Ambulanspersonal upplever dessutom högt stresspåslag i arbetet. Resultatet visar även att de oregelbundna arbetstiderna påverkar ambulanspersonalens sömnkvalitét samt kost och motionsvanor negativt. De urvalsmetoder som använts i artiklarna är; slumpmässigt urval, stratifierat sannolikhetsurval, totalurval samt bekvämlighetsurval. Slutsats; Såväl muskelsmärta, störd dygnsrytm, sömnbrist, samt ökat stresspåslag hos ambulanspersonal kan relateras till yrkesutförandet. Oregelbundenheten i arbetet försämrar möjligheten att äta hälsosamt och träna regelbundet. Ambulanspersonal skulle gynnas av bättre träningsmöjligheter på arbetet, längre återhämtningstid och bättre möjligheter till regelbundna måltider. / Abstract Background; Ambulance personnel are in their work exposed for heavy lifting, often in non-ergonomic postures, and in many cases under time pressure. Ambulance personnel also work in shifts and sometimes 24-hours, resulting in a circadian rhythm. Aim; Describe how professional performence affects the physical healt of ambulance personnel and to describe wich sampling method, used in included articles. Method; The literature study has a descriptive design and consists of 12 scientific articles, selected from Cinahl and Scopus databases. In 10 of the articles there is a quantitative approach and 2 of them has a mixed approach. The articles were audited on the basis of similarities. In the methodologocal aspect; sampling method, diffrences and similarities has been audited. Results; The result showed that ambulance personnel in greater occurence than norm groups, suffer from muscle pain. Which can be related to high physical exposure and non-ergonomic postures. Ambulance personnel also experiencing high level of stress in their work. The result also showed that irregular working hours affect the ambulance personnel´s quality of sleep aswell as diet and exercise habits negatively. The sampling method used are; Randomized sampling, stratified probability sampling, total sampling and convenience sampling. Conclusion; Musclepain aswell as disruption of circadian cycles, lack of sleep and increased level of stress in the ambulance personnel can be related to professional performence. The irregularity in the work impair possibilities to eat healthy and exercise regularly. Ambulance personnel would benefit from better exercise opportunities at work, longer recovery and better possibilities to regular meals.

Background Handover occurs as a daily task for health care professionals in all levels of care. Handover between ambulance crew and emergency department staff stands for the first exchange of information about a patient’s condition. Different factors may impact the handover communication and make it vulnerable. Aim The aim is to highlight factors of importance at handover between the ambulance and emergency room. Method A literature review of thirteen studies with qualitative and quantitative research approach. The purpose of this literature review was to provide an overview of the area. Results Experiences for health care professionals is that communication is important for patient handover between ambulance and emergency department. This information, as well as how information is structured and communicated, is an important part of the handover process. Knowledge, skills, responsibility and professionalism is conducive for making professional judgments. Health care workers pressured work environment, and lack of organizational structure are factors that can compromise patient safety. Conclusion Lack of good work environment, structure and common language has a negative impact on communication. Good attitudes as active listening and interest among staff increases prerequisites for good cooperation in handover