Introduction: Long term care (LTC) residents require complete or extensive support, including 24-hour nursing and personal care. LTC residents contribute a greater number of emergency department (ED) visits when compared to community-dwelling older adults. Little is known about which resident-level characteristics at admission are predictive of LTC resident transfer to the ED. The objective of this thesis was to identify which admission characteristics are associated with ED transfers in Ontario, Canada. Methodology: I conducted a population-level retrospective cohort study using the Resident Assessment Instrument Minimum Data Set Version 2.0 (RAI-MDS). The cohort included 56,433 LTC resident admission assessments from January 1, 2017, to December 31, 2018. Logistic regression and 10-fold cross-validation were used to identify adjusted associations between characteristics routinely collected during LTC admission assessment and ED transfers. Model performance was assessed using the area under the receiver operating characteristics curve (AUC). Outcomes of interest included any ED use, potentially preventable, and low acuity ED transfers. Results: A recent change in medical orders, previous ED visitation, female sex, the presence of an indwelling catheter, and the need for oxygen therapy were informative predictors for any, potentially preventable, and low acuity ED transfers. Deterioration in cognitive status and change in behavior was influential to any ED transfers only. Urinary tract infections, pneumonia, indictors of delirium, and change in mood are unique to potentially preventable ED transfers, and antibiotic resistance is unique to low acuity ED transfers. Similar discrimination was reached for any ED use (AUC = 0.630), potentially preventable transfers (AUC = 0.659), and low acuity transfers (AUC = 0.645). Conclusion: The factors associated with ED transfers may be modifiable, and closer attention to these factors may help reduce ED transfers. Although the discriminability of the models was poor, advanced knowledge of informative characteristics can support upstream decision-making for clinicians. Future studies are required to validate these findings, derive risk scales, and demonstrate the utility of this model in health service planning. / Thesis / Master of Science (MSc) / Long term care (LTC) provides residents with 24-hour nursing and personal care. When the care or clinical needs of the resident cannot be met in the LTC facility, they may be transferred to the Emergency Department (ED). However, the ED’s are poorly situated to manage the distinct needs of older adults, given the sole focus on medical acuity rather than geriatric complexity. Unwarranted ED transfers are burdensome for LTC residents and increase their risk for adverse health events, such as nosocomial infections, delirium, and injuries. Understanding characteristics associated with ED transfers can help identify which residents may be at a risk of an ED transfer. The objective of this thesis was to identify which LTC resident characteristics at admission are associated with ED transfers in Ontario, Canada. A recent change in medical orders, previous ED visitation, female sex, the presence of an indwelling catheter, and the need for oxygen therapy were informative predictors for ED transfers.

The implementation of a fast track section is a commonly used strategy to improve patient flow in emergency departments (EDs). A fast track section reserves resources (beds, doctors and nurses) for lower acuity patients, and is thus aimed to reduce the wait time and length of stay of these patients. We use a discrete event simulation to investigate the impact of adding a fast track section to an emergency department. We quantify the effect of introducing a fast track on length of stay and waiting time to bed for low and high acuity patients in a crowded ED and compare it to an ED without fast track (Combined ED). We simulate a crowded ED by increasing the patient arrival rate, changing the acuity mix and increasing the time taken for admitted patients in the ED to obtain an inpatient bed (boarding time). We demonstrate that, when compared to a Combined ED with the same number of resources, the introduction of a fast track reduces the wait time to bed for lower acuity patients. However, this comes at the cost of increased waiting time for some higher acuity patients, which is unacceptable in practice. In investigating the solutions to this problem, we find that changing patient prioritization is the most effective way of reducing wait times under crowding. This change in priority does not require the addition of beds, doctors and nurses, and is therefore a cost-effective approach. Finally, we discuss the implications of our results for emergency departments.

Introduction: Of the 119.2 million visits to the emergency department (ED) in 2006, it was estimated that about 249,000 visits resulted in the patient dying or being pronounced dead on arrival. In two national studies of emergency nurses' perceptions of end-of-life (EOL) care, ED design was identified as a large and frequent obstacle to providing EOL care. The purpose of this study was to determine the impact of ED design on EOL care as perceived by emergency nurses. Methods: A national, geographically dispersed, random sample of 500 members of the Emergency Nurses Association were sent a 25-item questionnaire regarding ED design as it impacts EOL care. Inclusion criteria were nurses who could read English, worked in an emergency department, and had cared for at least one patient at the EOL. Descriptive statistics were calculated for the Likert-type and demographic items. Open-ended questions were analyzed using content analysis. Results: After two mailings yielding 198 usable responses, nurses did not report ED design to be as large an obstacle to EOL care as previous studies had suggested. Nurses did report the ED design helped EOL care at a greater rate than it obstructed EOL care. Nurses also believed they had little input into unit design or layout changes. The most common request for design change was private places for family members to grieve. Thirteen nurses also responded with an optional drawing of suggested emergency department designs. Discussion: Overall, nurses reported some dissatisfaction with ED design, but also believed they had little to no input in unit design improvement. Improvements to EOL care might be achieved if ED design suggestions from emergency nurses were considered by committees that oversee remodeling and construction of emergency departments. Further research is needed to determine the impact of ED design on EOL care in the emergency department.

The Emergency Department (ED) as a workplace for the Registered Nurse (RN) is a stressful environment. Reasons are thought to include interactions with other members of the interdisciplinary team as well as the situations associated with the environment of the ED such as trauma, death, sadness, joy and the general unpredictability of each moment. Studies have documented general health care workplace stress and its influence on staff, but a very limited number of studies have concentrated on the ED. No widely published studies have identified stressors from the perspective of the ED RN. This dissertation is an interpretive phenomenological study that seeks to understand the experience of being an ED RN through the exploration of the perceptions of stress as lived by individuals who practice their art and science in this unique setting. Materials for evaluation and thematic identification were obtained through personal interviews of practicing nurses. The stories told by the participants communicated what each individual found to be negatively stressful as well as what each found to be positively stressful. Conclusions based on the findings of this work suggest a need for the ED RN to be able to depend on the presence of several factors in order to be able to function with as little distress as possible. The optimal ED environment for the RN is posited to be supportive of the individual goals of the RN, provide adequate resources and foster a communicative interdisciplinary environment. Recommendations are made to improve resource management and interdisciplinary relations

Syftet med studien var att beskriva sjuksköterskors erfarenheter av att vårda patienter med trauma på akutmottagningar. Resultatet i studien grundades i 10 vetenskapliga artiklar med kvalitativ metod, som analyserats och granskats. Från de analyserade artiklarna framkom två huvudteman och fem underteman som sammanfattningsvis beskriver sjuksköterskans emotionella utmaningar, omgivningens inverkan, kollegornas och teamarbetets betydelse, samt personliga strategier för att orka i det fortsatta arbetet. Att som sjuksköterska arbeta nära patienter som inkommer med ett trauma på akutmottagningar kan vara känslofyllt, stressigt och ångestladdat. Sjuksköterskorna i de utvalda artiklarna vittnar om hur det är att arbeta inom traumavården, stunder då det fungerar bra och situationer som varit utmanande. Resultatet beskrev även att erfarenhet hade stor betydelse, både när det handlade om kunskap och hanteringen av det emotionella i efterförloppet. Stödet från kollegor är extra betydelsefullt i efterförloppet efter en traumatisk händelse inträffat. Att det finns någon att dela sina erfarenheter med som varit med om samma sak. Barn och ungdomar som inkommer med trauma, var det som sjuksköterskor uppgav var den svårasteemotionella utmaningen. En slutsats som kan dras är att det behövs mer kunskap i hur sjuksköterskors hälsa och mående påverkats i förlängningen av att arbeta nära traumatiska händelser. En särskild beredskap behövs när det gäller speciellt barn och ungdomar. I bakgrunden beskrevs trauma och akutmottagningar med fokus på sjuksköterskeprofessionen, sjuksköterskans funktion och ansvar samt tidigare forskning. De omvårdnadsteoretiska begrepp som valdes var “hälsa” och “miljö”. Metoden som användes var en litteraturbaserad studie med analys av kvalitativ forskning för att öka förståelsen för det fenomen som studerades. I diskussionen diskuterades de resultat som framkommit gällande sjuksköterskors erfarenheter av arbetet på akutmottagningar inom traumavården

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.

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.

Thesis / Doctor of Philosophy (PhD)

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No description available.