The hospital emergency department (ED) is a critical source for health care amid a complex healthcare system in the United States. It is the gateway to care for a broad range of people, arriving from a variety of locations. With this wide reaching net and a decreasing trend in hospital beds, EDs throughout the United States are experiencing overcrowding. ED crowding has various tactical and strategic facility management impacts ranging from facility occupancy issues to adverse health outcomes. Among other factors, recent research has cited the sharp increase in ED visits over the years and ED patient boarding as key contributors to crowding. Home hospital care is a model in which health care is delivered at an individual’s home as a substitute for hospital-level inpatient short-term acute care. Clinical research has shown home hospital to be an effective care model for select illnesses presenting frequently to EDs, such as congestive heart failure, community acquired pneumonia, chronic obstructive pulmonary disease, and cellulitis. While there exist distinct clinical and social criteria for which delineate eligible individuals, home hospital care models have been linked with the potential to free inpatient beds. The overarching objective of this study is to investigate the relationship between home hospital care and ED crowding. To achieve this objective, the study examined the relationship between home hospital care and ED crowding, specific to ED boarding performance at a large, urban, teaching hospital facility. A methodology for identification of potential home hospital patients was used through clinical and social criteria, and a scale for the range of clinical eligibility rates was established for the five suitable illnesses. The study modeled patient flow and bed demand, and utilized computer simulation modeling to assess the impact of home hospital care on ED boarding performance. Various models were simulated to represent different home hospital intervention types. The models incorporated home hospital through an ED Referral program, Inpatient-Transfer Referral program, Community Referral program, and a fully integrated home hospital program. Three scenarios were run for each model to assess practical possibilities for the utilization of the freed bed hours from a home hospital program. This research contributes insight and understanding of home hospital’s impacts on ED crowding. The insight from this study quantifies the effects of a home hospital program on ED boarding and inpatient bed demand. The modeling study is contributes an analytical understanding of the impacts that home hospital could potentially have on crowding, which could prove useful in the struggle against ED congestion. This understanding helps to provide a more thorough understanding of home hospital, and could aid in an organization’s decision-making process of whether to implement a program. The presented modeling methodology for analyzing home hospital and ED crowding can also be used as a model format for researchers and practitioners for analytical purposes in future studies.

Bakgrund: På en akutmottagning kommer patienter i olika tillstånd och behov. Det är sjuksköterskan som ofta gör de första bedömningarna och därför är det av stor vikt att bemötandet från sjuksköterskan är positivt för att skapa trygghet. Ökat patientflöde och långa väntetider är några faktorer som är påvisade att kunna påverka upplevelsen för patienterna av sin vistelse på akutmottagningen. Syfte: Syftet med litteraturöversikten var att beskriva faktorer som påverkar patienters upplevelse av omvårdnad under sin vistelse på akutmottagning. Metod: Studien genomfördes som en litteraturöversikt. Databaserna CINAHL och PubMed användes för att söka efter artiklar. Resultat: Sex underkategorier valdes ut: bemötande, delaktighet, information, väntetid, kommunikation och kontinuitet, sjuksköterskans kunskap och kompetens. Resultatet visade att många patienter ansåg att sjuksköterskan var skicklig i sina arbetsuppgifter och var nöjda med bemötandet från sjuksköterskan, men att långa väntetider och bristande information påverkade upplevelsen av omvårdnad. Det fanns en tydlig önskan över att få mer information om sin väntetid, behandling och undersökningar. Brister i detta, skapade en otrygghet och en känsla av vara bortglömd hos patienterna. Slutsats: Sjuksköterskor på en akutmottagning behöver besitta en stor kommunikationsförmåga. Detta för att kunna ge patienterna en så bra upplevelse som möjligt. Slutsatser av resultatet har påvisat att det krävs förbättring inom flera områden för att ge patienter en bättre upplevelse av omvårdnaden under sin vistelse på akutmottagningen. / Background: To an emergency department people arrives with various states and needs. It is the nurse who often do the initial assessments and therefore it is of great importance that the response from the nurse is positive, to provide a feeling of security for the patient. Increased patient flow and long waits are a few factors that are proven to influence patients´ experience of their stay at the emergency department. Purpose: The purpose of the literature review is to describe factors that influence patients’ experience of care at the emergency department. Methods: The study was conducted as a literature review. CINAHL and PubMed databases were used to search for articles. Results: The analysis led to six subcategories: the encounter, participation, information, waiting time, communication and continuity, the Registered Nurse knowledge and skills. The results showed that many patients felt that the nurse was skilled with the nursing assignments and were happy with the response from the nurse, but the long waiting time and lack of information affected the experience of the nursing care at the emergency department. There was a clear desire from the patients to receive more information about their wait time, treatment and examination. Shortcomings of this, created insecurity and a feeling of being forgotten for the patients. Conclusion: Nurses at an emergency department need to possess great communication skills. To be able to give patients the best experience as possible at the emergency department. Conclusions of the results have shown the need for improvement in several areas, to increase a better experience for the patients during their stay at the emergency department.

<p>In 1995 and 2000 a total of 29 886 non surgical ED visits at Uppsala University Hospital were registered. Presenting complaint, admittance to a ward, length of stay, in-hospital mortality, discharge diagnoses, 30-day and long-term mortality were registered. The presenting complaints were sorted into 33 presenting complaint groups (PCGs). </p><p>For different PCGs there was different in-hospital fatality rate. Compared to the largest PCG, chest pain, the gender and age adjusted OR was 2.12 (95% CI 1.01 – 4.44) for the miscellaneous complaint group and 2.04 (95 % CI 1.35 – 3.08) for the stroke–like symptom group. Within a given PCG the in-hospital mortality could vary depending on discharge diagnoses. By relating PCG and long term mortality to the expected mortality in the population, the Standardized Mortality Ratio (SMR) could be calculated. The SMR was found to be highest in seizure 2.62 (95 % CI 2.13 – 3.22), intoxication 2.51 (95% CI 2.11-2.98) and symptoms of asthma 1.8 (1.65 – 2.06). For the same discharge diagnoses the long term mortality could differ considerably depending on PCG at ED arrival (p<0.001). </p><p>Between 1995 and 2000 there was a 30 % increase in ED visits at the non surgical ED. PCGs representing lesser severe conditions had increased. Demographic changes could account for 45 % of the increment and the remaining increase could be ascribed to change in visiting pattern. </p><p>In the 2000 cohort 41.0 % of all visits were performed by re-visitors. The number of revisits and five-year mortality had an inversed u-shaped relationship were patients with three re-visits within the same year had an increased mortality compared to patients with more or less visits. </p><p>Conclusion: It is possible to define presenting complaint groups (PCGs) that are robust and consistent over time and useful as a tool for epidemiological studies in the ED.</p>

Background: Health information exchange technologies are currently being implemented in many practice settings with the promise to improve quality, efficiency, and costs of care. The benefits are likely highest in settings where entry into the healthcare system is gained; however, in no setting is the need for timely, accurate, and pertinent information more critical than in the emergency department (ED). This study evaluated the use of a payer-based electronic health record (EHR) in an ED on quality, efficiency, and costs of care among a commercially insured population.Methods: Data came from a large health plan and the ED of a large urban ED. Visits with the use of a payer-based EHR were identified from claims between 9/1/05 and 2/17/06. A historical comparison sample of visits was identified from 11/1/04 to 3/31/05. Outcomes included return visits, ED duration, use of laboratory and diagnostic imaging, total costs during and in the four weeks after, and prescription drug utilization.Results: A total of 2,288 ED visits were analyzed (779 EHR visits and 1,509 comparison visits). Discharged visits were associated with an 18 minute shorter duration (95% CI: 5-33); whereas, the EHR among admitted visits was associated with a 77 minute reduction (95% CI: 28-126). The EHR was also associated with $1,560 (95% CI: $43-$2,910) savings in total plan paid for the visit among admitted visits. No significant differences were observed on return visits, laboratory or diagnostic imaging services and total costs over the four week follow-up. Exploratory analyses suggested that the EHR may be associated with a reduction in the number of prescription drugs used among chronic medication users.Conclusion: The EHR studied was associated with a significant reduction in ED duration. Technologies that can reduce ED lengths of stay can have a substantial impact on the care provided to patients and their satisfaction. The data suggests that the EHR may be associated with lower health plan paid amounts among admitted visits and a reduction in the number of pharmacy claims after the visit among chronic users of prescription drugs. Additional research should be conducted to confirm these findings.

Bakgrund: Hos sjuksköterskor på akutmottagning råder delade meningar om närståendes närvaro vid hjärt-lungräddning. Detta kan bero på om sjuksköterskan har positiva eller negativa upplevelser av situationen. Sedan flera år finns internationella riktlinjer skrivna som förespråkar närståendes närvaro, dessa används generellt inte i någon större utsträckning. Syfte: Att belysa sjuksköterskans upplevelse av närståendes närvaro vid hjärt-lungräddning på akutmottagning. Metod: En litteraturstudie har genomförts med 12 kvalitativa och kvantitativa vetenskapliga artiklar. Resultat: Under senare år har majoriteten av sjuksköterskorna gått från negativ inställning till positiv för närståendes närvaro vid HLR. Att närstående varit närvarande i de fall där HLR inte varit lyckad trodde sjuksköterskorna kunde underlätta det kommande sorgarbetet. Sjuksköterskorna trodde att närstående lättare kunde acceptera det plötsliga dödsfallet om de fick beröra, ta farväl och vara ett stöd den sista stunden i livet för sin familjemedlem. Slutsats: För att sjuksköterskan ska kunna behålla sin positiva upplevelse till närståendes närvaro vid HLR på akutmottagning krävs utvecklings–och förbättringsarbete. I detta arbete krävs både teoretisk och praktisk utbildning inom området. Samt etablering av de internationella riktlinjerna till lokala riktlinjer. / Background: Among nurses in emergency department is a difference of opinion regarding the issue of relatives being present during cardiopulmonary resuscitation. This can depend on the nurse have positive or negative experience of the situation. Since several years international guidelines are written to recommend relatives being present but in general they are not used. The aim: Of this study was to explain nurse’s experiences of relative’s presence during cardiopulmonary resuscitation in emergency department. Method: A literature review in which 12 qualitative and quantitative scientific papers have been reviewed. Results: During the last years most parts of the nurses changed their opinion from negative to positive regarding to relatives being present at CPR. If relatives been present when CPR wasn´t successful the nurses believed could help the coming grieving process. Nurses believed that relatives easier could accept the sudden death if they were able to touch, to say goodbye and share the last moments in life with their family member. Conclusion: To maintain the nurse positive experience of relative presence during CPR in emergency department needs development- and improvement work. This work needs both theoretical and practical education. And also there are needs to establish the international guidelines to local guidelines.

Bakgrund: För många patienter blir besök på en akutmottagning den första kontakten med hälso- och sjukvården. Bemötandet från sjuksköterskor på akutmottagningen behöver därför bli lyckat för att patienten ska kunna känna sig sedd och omhändertagen. Ett lyckat första bemötande från sjuksköterskan lägger grunden för en fortsatt god och säker vård. Syfte: Syftet med litteraturöversikten var att beskriva hur patienter upplever bemötandet från sjuksköterskor på en akutmottagning. Metod: Examensarbetet genomfördes som en litteraturöversikt och inkluderar 12 vetenskapliga artiklar, varav fyra med kvalitativ ansats, sju med kvantitativ ansats och en med mixad metod. Artiklarna söktes i databaserna CINAHL och PubMed. Resultat: I litteraturöversiktens resultat presenteras hur patienters upplevelser av bemötande från sjuksköterskor på en akutmottagning kan påverkas positivt såväl som negativt. Faktorer som påverkade upplevelsen av bemötande var information, kommunikation och patientmedverkan. Slutsats: Litteraturöversikten visar att sjuksköterskan bör implementera ett arbetssätt som främjar god kommunikation och patientdelaktighet för att möjliggöra goda upplevelser för patienter på en akutmottagning. Av betydelse är att sjuksköterskan för en bra kommunikation till patienterna, informerar på ett adekvat sätt samt att patienterna får känna sig väl omhändertagna och trygga. / Background: For many patients the visit to an emergency department is their first contact with the healthcare system. The encounter between the nurse and patient at the emergency department needs to be successful, so the patient can feel taken care of and seen. The first encounter creates the structure for a continuous safe and good quality of care. Aim: The aim of the literature review was to describe how patients’ experience the encounter with nurses in a emergency department. Method: The thesis was conducted as a literature review and includes 12 scientific articles, out of which four had a qualitative approach, seven with a quantitative approach, and one with mixed method. Articles were searched in the databases CINAHL and PubMed. Results: The result presents how patients’ experiences of encounters with nurses in an emergency department can be affected positively as well as negatively. Factors that influenced the experience of treatment were information, communication and patient involvement. Conclusion: The literature review shows that the nurse should use an approach that promotes good communication and patient participation to enable good experiences for patients in an emergency department. Of importance is that the nurse use good communication skills with patients, informing adequately and that patients may feel well cared for and safe.

Background: Trauma is the leading cause of death for people up to 40 years and causes great suffering for the affected person. When the person comes into the emergency department, it requires fast treatment and a structured approach from all of the trauma group. Every minute is important for the patient's prognosis. The encounter between the patient and the nurse is often short and intense. Aim: The purpose of this study is to describe patients' experience of care for physical trauma in an emergency department. Method: Articles have been applied for in the various relevant databases. Articles that answered the purpose was gathered and data were marked. This is to get an overview of the state of knowledge, which is compiled in the result. Results: The result shows that the communication and information were an important part of the care. Patients wanted the nurses to be honest and give clear information for patients, because it had impact on the experience of care. Feelings that arose in the connection with trauma was fear of the unknown, and not to hold control over their lives. Conclusion: Trauma care is a complex situation. The patient, purely somatic are in a life threatening situation but the mind is still present with many thoughts and questions. As the situation is life-threatening, the psychosocial needs will never be a priority of the traumacare. It will probably always remain, if no changes in the trauma team structure occurs. / Bakgrund: Trauma är den vanligaste dödsorsaken för människor upp till 40 år och medför stort lidande för den drabbade personen. När personen kommer in till akutmottagningen krävs snabbt omhändertagande och ett strukturerat arbetssätt från alla ur traumteamet. All tid är viktig för patientens prognos. Mötet mellan patienten och sjuksköterskan blir ofta kort och intensiv. Syfte: Syftet med litteraturstudien är att beskriva patienters upplevelse av omhändertagande vid fysiskt trauma på en akutmottagning. Metod: Artiklar har sökts i olika relevanta databaser. Artiklar som besvarade syftet samlades in och data markerades. För att få en översikt över kunskapsläget som har sammanställts under resultatet. Resultat: Resultatet visar att kommunikation och information var en viktig del i omhändertagandet. Patienterna ville att sjuksköterskorna skulle vara ärliga och ge tydlig information till patienterna, eftersom det hade påverkan på upplevelsen i omhändertagandet. Känslor som uppkom i samband med trauma var rädsla för det okända, och att inte inneha kontroll över sitt liv. Slutsats: Traumaomhändertagandet är en komplex situation. Somatiskt befinner sig patienten i en livshotande situation, men sinnet är fortfarande närvarande med många tankar och frågor. Eftersom situationen är livshotande, bortprioriteras alltid de psykosociala behoven patienten har i omhändertagandet och så kommer det förmodligen alltid att förbli. Om inte förändringar i traumateamets struktur sker.

Tracheal intubation in critically ill patients is a high-risk procedure. The risk of complications increases with repeated or prolonged attempts, making expedient first attempt success the goal for airway management in these patients. Patient-related factors often make visualization of the airway and placement of the tracheal tube difficult. Physiologic derangements reduce the patient's tolerance for repeated or prolonged attempts at laryngoscopy and, as a result, hypoxaemia and haemodynamic deterioration are common complications. Operator-related factors such as experience, device selection, and pharmacologic choices affect the odds of a successful intubation on the first attempt. This review will discuss the 'difficult airway' in critically ill patients and highlight recent advances in airway management that have been shown to improve first attempt success and decrease adverse events associated with the intubation of critically ill patients.

Bakgrund: I dagens samhälle är det många människor som söker sig till akutmottagningen av olika orsaker. På grund av den stora mängden patienter kan arbetsbelastningen bli hög för vårdpersonalen, och de kan därför tvingas prioritera medicinska aspekter före de psykologiska behoven. Patienterna kan därför uppleva mötet på akutmottagningen som okänsligt. Syfte: Syftet är att undersöka patienters upplevelse av bemötande från vårdare på akutmottagning. Metod: Litteraturstudie. Resultat: Resultatet visar på fyra övergripande teman: det första mötet på akutmottagningen, bra bemötande, dåligt eller bristande bemötande och informationens betydelse för patienten. Diskussion: I diskussionen beskrivs bland annat patienters upplevelse av bemötande i förhållande till begreppet livsvärld, men även hur informationen och väntetiden kan påverka patientens vistelse på akutmottagningen. Konklusion: De flesta patienter uttrycker tillfredsställelse över bemötandet och informationen som de får i första mötet på akutmottagningen. Efter det akuta skedet upplever dock många patienter att informationen och bemötandet fallerar och blir sämre. / Background: In todays society many people are seeking care at the emergency department for different reasons. The caregivers are because of the pressured workload, forced to prioritize the patient's medical issues over their psychological needs. Therefor in an urgent situation the patients can perceive the care as insensitive. Aim: the aim was to describe patients perception of the interpersonal encounter with caregivers in the emergency department. Method: literature study. Result: The result shows four overall themes: the first encounter at the emergency department, patient perception of good encounter with caregivers, bad or lack of encounter from the caregivers and the informations meaning for the patients. Discussion: In the discussion patients experience of treatment is described in contrast to the concept of life-world. Furthermore the importance of information and how waiting times affect the experience is illustrated. Conclusion: Most patients express satisfaction with the response and the information that they receive in the first meeting at the emergency department. However after the acute stage many patients express that the information and treatment doesn’t maintain the same standard as before.

Bakgrund: Akutmottagning är en del av vårdkedjan och mottagning på sjukhus där patienter kommer in med oväntad sjukdom och kritiska tillstånd för en första bedömning. Vården som bedrivs är intensiv och krävande av sjuksköterskorna. Syfte: Syftet med denna studie var att beskriva vilka erfarenheter sjuksköterskorna har av att arbeta på akutmottagning. Dessutom var syftet även att beskriva undersökningsgrupperna i de valda artiklarna. Metod: Föreliggande litteraturstudie har en deskriptiv design. Via PubMed inkluderades 15 artiklar varav åtta hade kvalitativ och sju kvantitativ ansats. För att specificera utfallet vid sökningarna användes årtalsbegräsningar, språk och tillgänglighet för högskolan i Gävle. Resultatet presenteras via fyra teman som uppkom vid analys av artiklarna genom läsning och färgkodning. Huvudresultat: Det framkom att sjuksköterskorna på akutmottagning upplever olika former av stress vilket påverkar de på olika plan. Patientpopulationen ökar ständigt vilket oroade sjuksköterskorna som i sin tur medförde ökad arbetsbelastning. Det framkom att behovet av utbildning och fler resurser av personal är stort. Arbetsmiljön är krävande med ett högt patientflöde, våld och hektiska arbetsdagar. Totalt antal deltagare i undersöknings-grupperna i valda artiklar var 1492. Slutsats: Den upplevda stressen påverkade sjuksköterskorna emotionellt och fysiskt, vilket gick ut över det sociala livet. Det är oorganiserat och ett högt patientflöde på akutmottagning vilket påverkar arbetsmiljön såväl som patientsäkerheten. Patientflödet bidrar även till långa väntetider och risken för våld ökades. Det framkom att fler resurser behövs samt mer utbildning till sjuksköterskorna. / Background: The Emergency department is a part of the hospital where patients comes with a critical condition and unexpected ilness for a first judgment. The healthcare provided is intense and demanding of the nurses. Aim: The aim of the study was to describe the nurses experiences of working in the emergency department. Our purpose is also to describe the study participants in the selected studies. Methods: The present literature review has a decpriptive design. PubMed was used and 15 articles were included, eight had a qualitative approach and seven had a quantitative. The limits that were used in the data collection was years, language and access for the university of Gävle. The data were analysed by color-coding and reading and the result is presented by four themes. Main Results: It was revealed the emergency department nurses were affected by the experience of various forms of stress. The patient population is constantly increasing, which concerned the nurses, which in turn led to increased workload. The need of education and more resources of nurses is big, and the work enviroment is demanding with a high patient flow, violence and hectic days. In the selected articles there was in total 1492 participants. Conclusion: The experience of stress affected the nurses emotionally and physically, which also affected the social life. The emergency department is unorganized with a high patientflow that affects the work enviroment and the patient safety. The high patient flow contributed also to a long waiting time which increased the risk of violence. More resources of nurses and education is needed