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

Emergency departments (EDs) are often thought of solely as places where life-saving interventions occur. However, EDs are also places where dying patients receive end of life care. Though research examining expert nurse behaviours in care of the dying has been conducted in a variety of care settings, little is known about this topic as it relates to care of the dying adult in the ED. A descriptive exploratory study was conducted with registered nurse experts (n = 6) in two urban EDs in Western Canada. Five expert nurse behaviours deemed essential in care of the dying adult patient in the ED were identified: 1) providing comfort; 2) honouring the personhood of the patient; 3) responding to the family; 4) responding after the death of the patient; and 5) responding to colleagues. These findings contribute to the empirical evidence concerning expert nursing care of the dying.

Reducing emergency department (ED) wait times are a major priority for the Ontario Government. Overcrowded EDs, cumulative effects of the delays in hospital processes and lack of resources are manifested in the phenomenon of long wait times. This thesis aims to estimate in real-time, a minimum wait time confidence interval for urgent abdominal pain patients on weekdays based on ED operations, waiting room status and ED census indicators through multivariate backwards stepwise regression modeling. The ED wait times model accurately predicted a 95% wait time confidence interval for patients. Common underlying factors attributed to long wait times include the total number of emergent and urgent patients in the waiting room, the total number of patient waiting for a consultation and the number of patients not seen within the Ontario Government’s target times. This information is useful in managing patient expectations and appropriately allocating resources to improve wait times.

Reducing emergency department (ED) wait times are a major priority for the Ontario Government. Overcrowded EDs, cumulative effects of the delays in hospital processes and lack of resources are manifested in the phenomenon of long wait times. This thesis aims to estimate in real-time, a minimum wait time confidence interval for urgent abdominal pain patients on weekdays based on ED operations, waiting room status and ED census indicators through multivariate backwards stepwise regression modeling. The ED wait times model accurately predicted a 95% wait time confidence interval for patients. Common underlying factors attributed to long wait times include the total number of emergent and urgent patients in the waiting room, the total number of patient waiting for a consultation and the number of patients not seen within the Ontario Government’s target times. This information is useful in managing patient expectations and appropriately allocating resources to improve wait times.

Background: The demand for hospice palliative care (HPC) services is expected to grow due to the increasing number of seniors living into advanced old age, the changing nature of death, and the changing family structure. HPC is a philosophy of care that aims to relieve suffering and improve the quality of life for clients with life-threatening illnesses or end of life issues. The goals of HPC are not only to ameliorate clients’ symptoms but also to reduce unneeded or unwanted medical interventions such as emergency room visits or hospitalizations (ERVH). Hospitals are considered a setting ill-prepared for end of life issues. Therefore, use of such acute care services has to be considered an indicator of poor quality end of life care. It is important to understand the factors that contribute to ERVH in order to determine how to minimize the number of avoidable hospital visits. Objectives: The objectives of this study were to report the proportion of palliative home care clients with ERVH, describe the characteristics of clients with ERVH, and identify the predisposing, enabling, and need-for-care variables associated with ERVH. Methods: Analysis of secondary data was performed on a palliative home care dataset from the Hamilton Community Care Access Centre (CCAC). All palliative home care clients receiving services from the Hamilton branch were assessed using the interRAI Palliative Care (interRAI PC), which is a comprehensive, standardized instrument. One assessment for each client assessed between April 2008 and July 2010 was used, for a final sample size of 764. Results: Half of the palliative home care clients had one or more ERVH. Visits to the emergency department by time of the day and day of the week were relatively stable. Logistic regression and Cox regression analyses showed that wish to die at home and advance care directives are protective against ERVH. Unstable health, identified by a Changes in Health End stage disease and Signs and Symptoms scale (CHESS) score of 3 or higher, was associated with reduced odds of ERVH, while infections such as prior pneumonia and prior urinary tract infections increased odds of ERVH. Conclusions: Predisposing characteristics (i.e., wish to die at home and advance care directives) are nearly as important as need variables (i.e., CHESS and prior urinary tract infection) in determining ERVH among palliative home care clients, which challenges the assumption that need variables are the most important determinants of ERVH. There was a lack of significant association between many assessed needs and ERVH, perhaps due to the fluctuating health status among such clients and the stability of measurements. Ongoing assessment of palliative home care clients is essential in reducing ERVH, as reassessments at specified intervals will allow care and service plans to be adjusted with clients’ changing health needs and end of life preferences.

Class of 2012 Abstract / Specific Aims: 1• Determine the results of urine culture and susceptibility testing for patients with uncomplicated UTI at an emergency department 2• Determine empiric antibacterial agents prescribed for treatment of uncomplicated UTI in the emergency department 3• Compare pathogen susceptibility pattern specific for patients with uncomplicated UTI compared to the overall institution antibiogram Examine the use of cephalexin for uncomplicated UTI in emergency department patients Methods: A retrospective electronic medical records of adult female patients admitted to University Medical Center in Tucson, Arizona, emergency department with a diagnosis of uncomplicated urinary tract infection (UTI) between June 1, 2010 and May 31, 2011 were collected. Different aspects of uncomplicated urinary tract infection (UTI) were characterized, and prescriptions for empiric antibiotic treatment were recorded. Culture results and susceptibility reports as well as antibacterial treatment decisions were studied to evaluate types of pathogens and resistance patterns along with therapy prescribed. The data was managed and analyzed by using SAS. All data was tabulated and described using summary statistics. Main Results: The dominant isolate of the study population was E.coli (88%). Cephalexin was prescribed 76% of the time, nitrofurantoin 8.4%, ciprofloxacin 7.6%, and TMP/SMX 5% of the time. The susceptibility rate of ampicillin was 50%, cefazolin 91%, ciprofloxacin 98%, nitrofurantoin 92%, and TMP/SMX 76%. Conclusions: Our study revealed that the resistant rate of TMP/SMX exceeded 20%; however, ciprofloxacin and nitrofurntoin susceptibility remains high. Cephalexin was the most commonly prescribed treatment, but not included in the antimicrobial susceptibility test (AST) panel.

Class of 2012 Abstract / Specific Aims: To evaluate associations between hospital and patient characteristics and mortality and economic outcomes. Included records were of adult patients age 18 years or older with a diagnosis of primary or disseminated liver cancer. Methods: This study was a retrospective cohort design that utilized emergency department discharge records from the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP) National Emergency Department Sample (NEDS). Generalized linear models were used for analyses to assess outcomes of mortality and total charges. Logistic regression was utilized for mortality; gamma regression with log-link was utilized for charges. Main Results: Overall, 239,895 adult records were included in the study with diagnoses of ICD-9 155.x or 197.7. Total charges for all records were over $8.23 billion in 2009. The average age of the case was 65.07 (±13.8) years with 48.7% being female. Mortality (either in the ED or hospital) was 11.1% (n=26,701). The mean length of stay was 6.47 (±6.05) days. Charges for each record were $42,874.50 (±53,956.34). Increased mortality was associated the most with hospital teaching status and primary payer. Increased charges were associated with hospitals located in the Western region. Conclusions: The differences in clinical outcomes were primarily from different payers and economical outcomes differed greatly by the Western region hospital location. Data taken from the nationally-representative investigation reveals that primary and disseminated liver cancer still remains a clinical high burden-of-illness with an 11.1% mortality rate and total charges approaching $10.3 billion dollars.

This dissertation addresses some of the gaps in the research on pediatric mental health (MH) repeat visits to the emergency department (ED). The primary objectives of this thesis are to systematically review the existing literature on youth MH return visits to the ED and to determine the incremental contribution of family factors in predicting these repeat ED visits. The first study systematically reviewed and qualitatively summarized the available literature to better understand predictor of repeat visits. A search was performed using the following databases: PsycINFO, PubMed, and CINAHL. Reporting followed the PRISMA statement checklist and methodological quality was assessed using the following eight criteria: design, generalizability, breadth of predictors, reporting of effect sizes, additional outcomes, interaction terms, confounding variables, and clear definition of outcome. A total of 178 articles were retrieved; 11 articles met inclusion criteria. Findings revealed that repeat visits to the ED for MH concerns is a complex phenomenon that can be attributed to various demographic, clinical, and MH care access and utilization factors. Common predictors associated with repeat ED MH visits included socioeconomic status, involvement with child protective services, as well as previous and current MH service use. For studies using a six-month repeat window, the most common factors were previous psychiatric hospitalization and currently receiving MH services. This systematic review concluded that in order to further elucidate which variables are most significantly associated with repeat ED visits; future research should consider the use of prospective designs and the inclusion of family factors. Investigating recency and frequency outcomes may also be of importance. The second study aimed to determine if family characteristics are significantly associated with repeat ED visits over and above the contribution of demographic, clinical or service utilization factors. A retrospective cohort study of youth aged six to18 years treated at a tertiary pediatric ED for a discharge diagnosis related to MH was conducted. Data were gathered from medical records, telephone interviews, and questionnaires. Of 266 participants, 70 (26%) had a repeat visit. Receiving MH services within six-months of the index visit, having a parent with a history of treatment for MH concerns, higher severity of symptoms and living closer to the hospital were significantly associated with repeat visits as well as earlier and more frequent repeat visits. Prior psychiatric hospitalization was associated with repeat visits and more frequent repeat visits, while presenting with suicidality was associated with more frequent repeat visits. Family functioning and perceived family burden were not associated with repeat ED visits. This thesis contributes to the growing literature on ED use in pediatric patients with mental illnesses and may be clinically useful to professionals working with repeat visitors. The identification of key factors could provide essential information to ED decision-makers and lead to the development of best practices with this population.

Class of 2012 Abstract / Specific Aims: Cellulitis accounts for the majority of skin and skin structure infections in patients who present to the emergency departments in the United States. The primary objective of this study was to evaluate the appropriateness of empiric cellulitis therapy prescribed in an emergency department of an academic medical center. The secondary objective of the study was to compare the cost-effectiveness of the empirical cellulitis therapy prescribed at the institution. Methods: This retrospective chart review study has been approved by the Institutional Review Board. Adult patients evaluated at an emergency department of a tertiary care, academic medical center, diagnosed with cellulitis and prescribed empiric antibiotic therapy between October and November 2010 were evaluated. Subjects were excluded if they required hospitalization or surgical intervention in an operating room or if they were diagnosed with necrotizing fasciitis, orbital cellulitis, or a diabetic foot infection. Data collected for each subject included type of cellulitis, therapy prescribed, and outcomes. Appropriateness of empiric cellulitis therapy was determined by expert opinion and guideline statements. A chi-square test was used to evaluate the statistical significance of treatment failure between the prescribed antibiotic groups. An independent t-test was used to analyze the cost between the prescribed antibiotic groups. An incremental cost-effectiveness ratio was used to determine the cost-effectiveness of the prescribed antibiotic groups. Main Results: The majority of patients were given a prescription for either clindamycin montherapy (37%) or trimethoprim-sulfamethoxazole plus cephalexin (40%) as empiric therapy when discharged from the emergency department. While follow-up (either repeat emergency department visit or clinic visit within the academic medical healthcare network) was only available in 78% of subjects, there was no statistical difference (p=0.51) in therapy outcomes between these two empiric therapy groups. Conclusions: Types of antimicrobials, doses, and duration of therapy prescribed for outpatient empiric cellulitis therapy at a single medical center were not consistent.

Class of 2015 Abstract / Objectives: To determine whether disparities exist among mental health patients admitted to the emergency department in regards to the prescribing patterns of injectable benzodiazepines and antipsychotics. Methods: A retrospective chart review was performed to evaluate patients with mental health diagnoses who received an injectable antipsychotic or benzodiazepine while in the emergency department of an academic medical center. A report was generated of all injectable antipsychotics and benzodiazepines removed from the emergency department Pyxis machines from November 1, 2013 to January 31, 2014. Data from the patient medical record included the patient’s age, height, weight, gender, race/ethnicity, insurance information, mental health diagnosis, evidence of substance abuse, how they arrived in the emergency department, their length of stay in the emergency department, any signs of aggressive behavior (adapted from the Overt Aggression Scale), information about each injectable antipsychotic or benzodiazepine that was administered was recorded including the name of the medication, dose, route of administration. If the patient received multiple doses of the same medication during their stay, the total dose and the total time receiving the medication was also recorded. The prescriber’s gender and whether they were a resident or an attending physician was also recorded for each medication administered. Results: A total of 98 patient charts were reviewed and analyzed. Mental health diagnoses were broken down into categories of psychiatric disorders (39.8%), bipolar disorders (74.5%), mood disorders (40.8%), and personality disorders 54.1%). Of the 98 patients reviewed, 68% had a documented substance abuse, with 62% having a positive urinalysis for alcohol, illicit drugs, or opiates. The majority of the patients were white (64.3%). The next largest racial/ethnic categories were Hispanics (12.2%), Native Americans (8.2%), and African Americans (6.1%). There were 54 males and 44 females. Benzodiazepines comprised 74% of the medications administered with lorazepam being the most frequently administered medication overall at 63.4%. Haloperidol was the second most frequently administered medication at 22%. Initial Chi Square analysis did not yield any significant results with regards to race and prescribing patterns, gender and prescribing patterns, or insurance and prescribing patterns. Conclusions: Patients with mental health diagnoses suffer from disparities within health care, and when these patients fall under other demographic groups such as racial/ethnic minorities and low socioeconomic status, the disparate treatment they receive could be even greater. Several limitations to this study including a small sample size and lack of geographical diversity resulted in a lack of statistically significant results, and our findings may not be generalizable to other patient populations.