During recent reforms to the Taiwanese health care system, discharge planning for hospital patients has become an issue of great concern as a result of shorter hospital stays, increased health care costs and a greater emphasis on community care. There are around five million patients visiting in emergency departments (ED) per year in Taiwan with up to 85% of these, 4,250,000 emergency patients, discharged directly from the emergency department. This significant number of ED visits highlights the need to implement discharge planning in the ED. ED nurses are not only responsible for providing appropriate assessments of a patient's future care needs but also for implementing effective discharge planning as a legal obligation; discharge planning is also a patient's right in Taiwan. For ED nurses to function effectively in the role of discharge planner, it is important that they have a comprehensive understanding of implementing discharge planning. To date, no published research focuses on nurses' experience of implementing discharge planning in the ED in Taiwan. This study is the first step in identifying the experience and understanding of nurses in implementing discharge planning in the ED in Taiwan and may have implications worldwide. The purpose of this study was to identify and describe the experience and understanding of the qualitatively different ways in which ED nurses’ experience of implementing discharge planning for emergency patients in Taiwan. In order to identify and describe the experience of implementing discharge planning, the qualitative approach of a phenomenography was chosen. Thirty-two ED nurses in Taiwan who matched the participant selection criteria were asked to describe their experience and understanding of the implementation of discharge planning in the ED. Semi-structured interviews were audio-taped and later transcribed verbatim. The data analysis process focused on identifying and describing ways ED nurses’ experience and understanding of implementing discharge planning in the ED. There were two major outcomes of this study: six categories of description and an outcome space. These six categories of description revealed the experience and understanding of implementing discharge planning in the ED. An outcome space portraying the logical relations between the categories of description was identified. The six categories of description were implementing discharge planning as ‘getting rid of my patients’; implementing discharge planning as completing routines; implementing discharge planning as being involved in patient education; implementing discharge planning as professional accountability; implementing discharge planning as autonomous practice; implementing discharge planning as demonstrating professional nursing care in ED. The outcome space mapped the three levels of hierarchical relationship between these six categories of description. The referential meaning of implementing discharge planning was the commitment to providing discharge services in the ED. The results of this research contribute to describing the nurses’ experience in the implementation of the discharge planning process in the emergency nursing field, in order to provide accurate and effective care to patients discharged from the ED. This study also highlights key insights into the provision of discharge services both in Taiwan and World-wide.

A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / Research Question: Will trained volunteers significantly affect patient experience compared to educational fliers or no intervention? Background: Patient experience continues to be an important issue with our nation’s healthcare system especially with the adoption of Value Based Purchasing for hospital reimbursement. With the use of Honor Health Scottsdale’s large number of volunteers, we hoped to design and develop a program that will improve experience for patients presenting to a community based Emergency Department. Objective: To evaluate the impact of Emergency Department Volunteers on the patient experience.

Class of 2014 Abstract / Specific Aims: The aim of this study was to examine the appropriateness of antibiotic use in the first 48 hours of being admitted to the emergency department in a tertiary care medical center. The purpose was to identify inappropriate usage patterns of antibiotics to limit future misuse and prevent the unintended consequences of overuse of antibiotics. Methods: Patients 18 years and older who were admitted to the emergency department at University of Arizona Medical Center – University Campus who were administered imipenem within 48 hours of admission were included. All antibiotics received by included patient were recorded and assessed for appropriateness by two pharmacists with specialized infectious disease training. Inappropriate use of carbapenems or other antibiotics in conjunction with carbapenems was identified and the acquisition cost of the misused antibiotics was calculated. Main Results: Imipenem use was considered inappropriate in 35/52 (71.1%) of patients included in this study. The direct cost of inappropriate antibiotic prescribing was $914.77. Multiple β-lactam antibiotics were used in 24/52 (46.1%) patients while 18/52 (34.6%) of patients received four or more antibiotics within the first 48 hours of admission. Conclusion: Imipenem was frequently used empirically for in cases did not fit the predetermined criteria of use within 48 hours of admission emergency department of the University of Arizona Medical Center – University Campus, resulting in unnecessary direct costs to the medical center.

This work compares the procedures used in the Emergency Departments in the University of Benin Teaching Hospital (UBTH) in Nigeria and in Manchester Royal Infirmary (MRI) in the UK. It goes on to develop a discrete event model of the latter in Rockwell Arena®.Raw data from UBTH were obtained over a number of visits by interviewing senior administrators, clinicians and nursing staff and by tracking patients over a period of 2 months between 1 July and 29 August, 2011. Information from MRI was supplied through an approved ethical protocol to the National Research Ethics committee (REC Reference 13/NN/0175, IRAS ID 124168, dated March 4, 2013). This embraced patient journeys, locations, investigations and tests for the 98236 patients who attended the ED between April 2012 and March 2013. These (anonymised) data were obtained as spreadsheets from the original Symphony® records, which were then manipulated and analysed using the computer language, R. Anecdotal information on ED operations, patient flow and procedure duration times were also obtained from ED staff. All of this information identified similarities and differences between patient journeys in the two hospitals and were used to generate appropriate process maps. Proposals were made to improve the recoding and maintenance of patients’ records in UBTH. In the case of MRI, each patient’s journey was expressed as a journey-string, which was an ordered list of locations and milestones derived from the time-stamps recorded in the original spreadsheets. A large transition matrix (168 by 168) was generated from the set of journey strings and established the probability of a patient going from one location to any another. This reflects all the decisions which were made at each step of the patient’s journey. The number of destinations from a particular source reflects the options available at a particular instant in time, while the size of each probability reflects the preferred destination. The transition matrix together with the duration and resource requirement of the process associated with the destination is the key to the generation of a process map for each journey through the system. This methodology is original and can be applied generally. This was used as a basis for the journey-path model. In the final MRI model the 4h deadline was not included since the mechanism for its actual implementation was somewhat vague. Instead some isolated models based on patients’ priorities and resource re-allocation were described. From these it was inferred that changing the priority of a patient may not in itself be sufficient to alter the journey profile and in order to do so resources must be re-allocated. The only alternative would appear to be the fast-tracking of patients.

No

Severe sepsis kills an estimated 1,400 people worldwide every day. This often fatal infectious process accounts for an estimated 215,000 deaths in the United States (US) annually. The main goal of this project was to evaluate the impact of the Emergency Department Severe Sepsis Alert and Practice Protocol (EDSSAPP) post implementation, on time to first antibiotic administration, length of stay, and mortality in patients admitted via the ORMC ED with severe sepsis. This study evaluated the time to first antibiotic administration, total ED and hospital length of stay (LOS) and mortality of severe sepsis patients either with a severe sepsis alert (SSA) activated or no alert activated that were admitted to the hospital through the ED. A retrospective review of the electronic medical record (EMR) was conducted to gather the required data across three time cohorts: base line/time zero (T0), six months prior to the implementation of EDSSAPP; Time one (T1) the first six months following initial EDSSAPP implementation; and Time two (T2), six months following reinstatement of the corporate sepsis committee. The most significant finding of this study was the increased number of Severe Sepsis Alerts activated in time cohort T2 (n=113) compared to T1 (n=19). Another important finding was the decreased mortality in T2 (16.4%) compared to T0 (22.7%) and T1 (33%). Overall, the number of ED patients with severe sepsis who received antibiotics within the EDSSAPP required 60 minutes did not consistently improve across the three time cohorts, T0 (81.8%), T1 (71.7%) and T2 (80.6%). The hospital LOS of stay was increased by almost 1.5 days between those patients with a severe sepsis alert activated in T1 (9.00 days) compared to time T2 (10.48 days). There was no significant decrease in the ED LOS across time cohorts and between groups of patients who had a SSA activated versus no alert activated. However, there was a 1 hour and 28 minute decrease in ED LOS in patients who had a severe sepsis alert activated in T1 compared to T0. In addition, there was a 1 hour and 52 minutes decrease in ED LOS between patients who had a SSA activated compared to those who had no alert activated in T2. While EDSSAPP data does not demonstrate the statistically significant results that was expected, the challenges related to adherence by providers to EDSSAPP is as it is seen in the literature. Increased awareness via consistent communication of on-going audit results to ED personnel will heighten their awareness for severe sepsis and EDSSAPP. Improved collaborative efforts with the interdisciplinary team are needed to refocus everyone's efforts to increase early recognition that is followed by appropriate treatment interventions and documentation is essential. Lastly, the development of a formal process to follow up with individual providers as close to real time as possible following a SSA that includes accountability for care provided and related documentation would also contribute to both awareness and adherence.

Yes

Rising demands and market competition have forced many emergency departments to improve their quality of service. This improvement is usually achieved at the cost of increasing resources in the emergency department in order to increase the patient satisfaction. This research deals in part with both problems, i.e., increasing patient satisfaction and keeping costs in the ED to a minimum. The research has schedules designed on the patient contacts for physicians and residents in the academic emergency department at York hospital such that the resource costs and patient waiting costs are kept at a minimum. The emergency department is simulated using Arena 7.0 and the minimum cost objective is achieved by running OptQuest for Arena to get the near optimal number of staff working the designed schedules in order to achieve the objective. Efficiently scheduling doctors and residents resulted in waiting cost reductions of almost 80%. There was also an increase in patient satisfaction, considering the time taken by patients to see a doctor or resident for the first time. The time was reduced by 33% for critical patients and was reduced by almost 29% for intermediate care patients with the schedules designed herein. / Master of Science

The purpose of this research is to determine an appropriate nurse staffing strategy for the Intermediate Care Unit (ICU) and the Critical Care Unit (CCU) of the Emergency Department at York Hospital in York, Pennsylvania. This strategy must adhere to certain administrative policies while keeping patient waiting times within allowable limits. Determining the proper number of resources in an emergency department is a difficult problem because while assistance must be provided without delay at any time, the available resources are restricted by the hospital budget. This research involves simulating the operations of the Emergency Department at York Hospital using the software package Arena 7.0 to evaluate how the system is impacted by various nurse staffing strategies. A microcomputer-based decision support system (DSS) for nurse scheduling that was first developed by Sitompul in 1991 has been implemented using Turbo Pascal 6.0 to generate twenty possible nurse staffing plans. The best alternative staffing plan has been evaluated by the simulation model to determine its effect on waiting times for patients. Specifically, patients are divided into five ESI levels, where ESI-1 patients are the most serious and ESI-5 patients are the least serious, and waiting times are provided for each patient type. While the DSS approach is useful in generating specific working schedules that are acceptable to the nurses' requirements, it is limited when developing an overall staffing plan. Specifically, the DSS requires a user-defined ratio of nurses working the various shifts, and this ratio must remain constant throughout each month even if patient arrival rates are known to be time dependent. As an alternative approach, OptQuest for Arena was employed to search for an overall nurse staffing plan. After providing Arena with 50 DSS-generated schedules that satisfy the nurses' requirements, OptQuest was used to determine the best schedule for each nurse to follow in order to minimize the average waiting time in the system for patients. Although the average waiting time obtained by the OptQuest staffing plan decreased from the current staffing plan for all patient types, a paired-t comparison determined using Arena's Output Analyzer indicated no statistical difference (at the 95% confidence level) between the DSS and OptQuest scenarios, in terms of the average waiting time for ESI-1 and ESI-2 patients. Further analysis indicated that a system bottleneck occurred in the triage area of the emergency department during evening hours. After adding one additional triage nurse in the evening shift, the OptQuest-generated staffing plan was re-evaluated. The results indicate that the suggested staffing plan reduced the average waiting time in the current staffing plan by 34.33%, 32.73%, 47.87%, 54.92%, and 52.41% for ESI-1, ESI-2, ESI-3, ESI-4, and ESI-5 patients, respectively. In addition, the average waiting time of ESI-1, ESI-2, ESI-3, ESI-4, and ESI-5 patients for the suggested staffing plan was 19.27%, 19.36%, 39.37%, 48.55%, and 46.64%, respectively, less than for the staffing plan determined when using the DSS approach alone. / Master of Science

Dysfunktionell stress bland sjukvårdspersonal är ett ökande problem i dagens samhälle. En av de vanligaste anledningarna för sjukfrånvaro bland sjukvårdspersonal är psykisk ohälsa och värk i rörelseapparaten på grund av dysfunktionell stress. Sjuksköterskor som måste ta itu med svåra skador och avlidna människor löper större risk att utsättas för höga nivåer av dysfunktionell stress. Ökad utsatthet för stress kan leda till en försämrad prestationsförmåga och en ökad risk för misstag som kan äventyra patientens säkerhet och hälsa. Litteraturstudien har för avsikt att beskriva orsaker till stress och dess påverkan på sjuksköterskan på en akutmottagning. Studien bygger på 10 vetenskapliga artiklar, sex kvantitativa samt fyra kvalitativa. Litteraturgranskningen resulterade i två teman. Administrativ och organisatorisk stress: Administrativ och organisatorisk stress härstammar primärt från en bristande blandning av personal med hög och låg kompetens, underbemanning, överbeläggningar samt omvårdnadskrävande patienter. Konflikter på grund av skillnader i senioritet, tjänstgöringstid, skillnader i vanor och arbetssätt ligger till grund för stress. Dåligt stöd har en stor påverkan på hur sjuksköterskor upplever stress. Vårdpersonal som känner stöd från kollegor och ledning upplever en större arbetstillfredsställelse, högre arbetsmoral och upplever mindre stress i arbetsvardagen. Patientrelaterad stress: Sjuksköterskor utsätts för våld samt traumatiska händelser i sitt vardagliga arbete som upplevs vara en stor orsak till stress. Ångest, skuldkänslor, rädsla samt utmattning är några känslor sjuksköterskor upplever efter hot och våld eller traumatiska händelser. Stress kan leda till minskad koncentrationsförmåga  och  fokus  bland  sjuksköterskor  vilket  kan  resultera  i  en försämrad vårdkvalité. Sjuksköterskor som utsätts för traumatiska händelser löper risk för att utveckla PTSD (posttraumatisk stress disorder). För att kunna tillfredsställa grundläggande behov, undvika lidande, bidra till ökat välbefinnande och inge trygghet hos patienten. Är det viktigt med en ökad insikt i sjuksköterskans stressfyllda arbetssituation på akutmottagningar.