Abstract Trends of Hospital Utilization among High-Utilizers of Inpatient Services in an Urban, Safety-Net Hospital Introduction: Although high-utilizers of healthcare services represent only a small portion of hospital population they account for huge healthcare cost in the United States. Hence, there is a need to understand the patterns of hospital utilization among high-utilizers in order to develop intervention to reduce overall hospital cost. Aim: To determine inpatient hospital utilization pattern among high-utilizers in Grady Hospital, Atlanta. Methods: Trend analysis was done to understand the pattern of health care utilization among high-utilizer (n=510) patients (HUPs) from 2011 to 2014. Multivariate logistic regression analysis was performed to determine the association between selected socio-demographic characteristics and HUPs. Results: Almost all HUPs were non-Hispanic Blacks (82.6%) with average mean age of 58. Significant proportion were employed with no health coverage. Approximately 27% of the 510 participants were HUPs at the end of 2012. At the end of 2013, the proportion of patients who became HUPs and NHUPs were 37% and 39% respectively. By 2014, 37% of patients who were HUP in 2013 remained HUP in 2014. Conclusion: The pattern of hospital utilization among high utilizers is unstable and unpredictable, and may be driven by race. Our study shows that reducing heath care cost may require developing predictive models to reduce hospital over-utilization usage among at risk group.

Bakgrund: Triage är ett hjälpmedel som används för att genomföra bedömningar och prioriteringar av patienter på akutmottagningar. Bedömningarna av patienterna delas upp i olika nivåer beroende efter deras vårdbehov. Syftet med bedömningarna är att se till att den som har störst behov av hjälp erhåller hjälp först. Det är en legitimerad sjuksköterska som utför denna bedömning. Syfte: Beskriva sjuksköterskans erfarenhet av att arbeta med triage på en akutmottagning samt beskriva vilken datasamlingsmetod som använts i de inkluderade artiklarna i resultatet. Metod: En litteraturstudie med deskriptiv design, där tio vetenskapliga artiklar inkluderades. Sökningar efter vetenskapligt material genomfördes i databaserna Cinahl och PubMed samt genom en manuell sökning i de båda databaserna. Artiklarna har granskats för att urskilja skillnader och likheter och sammanställts både i tabellform och i resultattext. Huvudresultat: I Resultatet framkom tre huvudfaktorer som påverkar sjuksköterskors upplevelse av triage: Klinisk erfarenhet, arbetsmiljön på akutmottagningen och teoretisk och praktisk utbildning. Valda artiklars datainsamlingsmetoder bestod av både intervjustudier, enkätstudier, observationsstudier. Slutsatser: Sjuksköterskor beskriver bristande utbildning, avsaknad av yrkeserfarenhet samt olika faktorer som påverkar arbetsmiljön på akutmottagningen som har visat sig ha betydelse för deras erfarenheter av att arbeta med triage. Faktorerna har var och en för sig betydelse för sjuksköterskors yrkesutövning, inte bara inom akutsjukvården, utan även inom andra verksamhetsområden inom sjukvården. Trots den stora variationen av patient tillströmning på akutmottagningar så uppger sjuksköterskor att arbetstillfredsställelsen är stor men om mer vikt lades vid att skapa en godare arbetsmiljö, erbjuda utbildning samt se över kliniska yrkeserfarenhetens betydelse vid triagering kanske arbetstillfredsställelsen skulle vara ännu högre. / Background: Triage is a tool used to carry out assessments and priorities of patients in emergency rooms. The assessment of the patients is divided into different levels according to their health needs. The purpose of the assessments is to ensure that those who have the greatest need of assistance are taken care of first. A registered nurse performs this assessment. Aim: To describe the nurse´s experience working with triage in a emergency department and to describe the data collection method used in the articles included in the result. Method: A literature study with descriptive design, were ten scientific articles were included. A search for scientific material was carried out ant retrieved from the University of Gävle databases Cinahl and PubMed and through a manual search of the two databases. Results: It emerged that nurses describes causes like lack of education, a lack of experience and factors that affect the work environment has been shown to be important for their experience in working with triage. Selected items data collections methods consisted of interview studies, surveys, observational studies and a web-based survey. Conclusion: The results reveled three main factors affecting nurse´s experience of triage: Clinical experience, work environment and education. The factors, each individually is important for nurse’s occupation, not just in emergency care, but also in other areas in healthcare. Despite the great variety influx of patients in emergency rooms the nurse’s professional satisfaction is but if more emphasis was placed on creating a more enjoyable working environment, providing training and reviewing clinical significance of professional experience at the triage then work satisfaction migh be even higher.

Background: The meeting between the patient and nurses is the foundation of health care. It is important to get an understanding of the patient's experience of care in the emergency department from his perspective, to reduce dissatisfaction and suffering and promote good health for patients.     Aim: The purpose is to get a comprehensive picture of adult patients' experiences of communication and participation in the emergency department.     Method: A literature review with thematic content analysis using deductive approach, based on 14 qualitative articles.     Results: According to the patients affected their experience of communication and participation in the emergency department how they will be attending nurse and visibility they get in their care situation. There were four themes based on the result, which is "to get individualized information creates knowledge," A mutual dialogue builds trust and security "," To not understand the medical aspects causing concern "and" Being able to control their health situation provides a greater understanding of health situation ". / Bakgrund: Mötet mellan patient och sjuksköterska utgör grunden i hälso- och sjukvården. Det är av stor vikt att få en förståelse för patientens upplevelse av omvårdnaden på akutmottagningen ur dennes perspektiv för att minska missnöje och lidande och främja en god hälsa hos patienter.   Syfte: Syftet är att få en översiktlig bild av vuxna patienters upplevelse av kommunikation och delaktighet på akutmottagningen.   Metod: En litteraturstudie med tematisk innehållsanalys och deduktiv ansats, baserad på 14 kvalitativa artiklar.   Resultat: Enligt patienter påverkas deras upplevelse av kommunikation och delaktighet på akutmottagning av hur de blir behandlande av sjuksköterskan samt den insyn de får i sin vårdsituation. Det uppkom fyra teman utifrån resultatet, vilka är “Att få individualiserad information skapar kunskap, “En ömsesidig dialog skapar tillit och trygghet”, “Att inte förstå de medicinska aspekterna skapar oro” och “Att kunna kontrollera sin vårdsituation ger ökad förståelse för vårdsituationen”.   Slutsats: Resultatet av litteraturstudien visar att kommunikation och delaktighet på akutmottagningen påverkas av patientens upplevda trygghet och kontroll över sin vårdsituation samt av förtroenden för sjuksköterskan. Patientens rädsla och oro under sin vårdtid kan minska när informationen är mer individanpassad eftersom denne känner sig mer delaktig och känner större kontroll över sin vårdsituation. Det är därför viktigt att sjuksköterskan lyssnar till patientens behov och bjuder in denne till en god och ömsesidig dialog. Det är lika viktigt för sjuksköterskan att förstå vikten av att involvera patienten i alla aspekter som rör patientens vårdsituation samt att kunna identifiera varje patientens behov av god omvårdnad.

Sepsis and its manifestation as a shock state in “septic shock” have long caused medical issues and death worldwide. The disease requires quick identification, diagnosis, and intervention with very high mortality rates prevalent otherwise. Historically this has been due to limited awareness of the disease and misclassification of its prevalence, severity, and incidence. Luckily in the past decade there has been increased interest and therefore resources devoted towards improving care and further understanding a disease that is one of the leading causes of mortality in hospitals worldwide. Over the past handful of years novel interventions and diagnostic techniques have become available. Unfortunately, in many cases these new discoveries have not yet trickled down to many of the providers on the frontline and a large amount of variation in care exists across the country. Because of the time sensitivity of sepsis, it is imperative that individuals working in the areas of healthcare who first come in contact with these patients have a clear understanding of the newest advances and resources available. In this thesis the goal is to first analyze the current protocols and standards of care for sepsis and then secondly consider new developments available both in the hospital and in prehospital emergency medical services (EMS). From the current information, strategies and protocols based on improvement of patient outcomes, can be streamlined and optimized moving forward. As predicted, there is currently an incredibly large amount of variation and knowledge on the subject with some areas implementing very progressive protocols while others still lack a sepsis protocol all together. In general, the current consensus in the field is that rapid identification and initiation of treatment is the most important component to long term survival. Improvement of outcomes therefore relies on standardization of protocols with incorporation of education components for healthcare providers. This aims to raise awareness and encourage utilization of the newest information and suggestions available. Increased interdisciplinary cooperation between prehospital providers in EMS and care providers in the hospital can also lead to improvement of recognition and treatment times for these patients. Future considerations were also examined that may potentially be applicable moving forward to improve these standards even further. There is a much opportunity available in each of these areas currently and progress is key to improving outcomes.

Thesis advisor: June A. Horowitz / Agitation is a distressing set of behaviors frequently observed in emergency department psychiatry patients. Key to developing and evaluating treatment strategies aimed at decreasing and preventing agitation is the availability of a reliable, valid instrument to measure behaviors representative of agitation. Currently, an agitation rating instrument appropriate for use in the emergency setting does not exist and clinicians are left without standard language for communicating about the phenomenon. The Agitation Severity Scale was developed to fill this void using facilitated focus groups to generate an initial item pool. Beginning evidence of content validity was established through a survey of clinical providers and a panel of content experts. The objectives of this methodological study were to: (a) develop an observation-based rating scale to assess the continuum of behaviors known as agitation in adult emergency department patients, and (b) to evaluate the psychometric properties of the newly developed instrument. Psychometric evaluation was conducted using a sample of 270 emergency department psychiatric patients. A 17-item instrument with a standardized Cronbach's alpha coefficient of 0.91 resulted, providing evidence of a high degree of internal consistency reliability. Principle components analysis revealed a 4-component solution accounting for 69% of observed variance. Internal consistency reliability ranged from 0.71 to 0.91 for the scale components. Equivalence reliability was established through the evaluation of Agitation Severity Scores assigned by independent evaluators, <italic> r </italic>= 0.99, &kappa = 0.98. Construct validity was established through comparison of mean scores for subjects in the highest and lowest scoring quartiles. A statistically significant difference in scores was noted when comparing these groups, <italic> t </italic> = -17.688, df = 155, <italic> p </italic> < 0.001. Convergent validity was evaluated by testing the association between Agitation Severity Scores and scores obtained using a well-established instrument, the Overt Agitation Severity Scale. Pearson's correlation coefficient for the associations between the scores ranged from 0.91 to 0.93, indicating a strong, positive relationship between the scores. Finally, the Rasch measurement model was employed to further evaluate the functioning of the instrument. In sum, the Agitation Severity Scale was found to be reliable and valid when used to measure agitation in the emergency setting. / Thesis (PhD) — Boston College, 2011. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

PURPOSE: Doppler renal resistive index (RRI) has emerged in the last decade as a useful prognostic indicator for transient (fluid responsive) and persistent acute kidney injury (AKI). The determinants of RRI are largely systemic and recent studies confirm that RRI measurement could also be a useful early marker for sub-clinical AKI and post procedural AKI risk. This study aimed to determine the feasibility of RRI measurement in an Emergency Department (ED) resuscitation room setting using a point­of­care ultrasound system. METHODS: In this prospective single centre study, RRI measurement was attempted in 20 non-consecutive patients (meeting the inclusion criteria) by a single expert sonographer. RRI measurements were evaluated against context specific feasibility criteria and target outcomes. RESULTS: 20 patients (11 male, 9 female) were recruited to the study. Age of patients ranged from 33 years to 91 years (mean 62.3 years). Adequate visualisation of both kidneys was achieved in 60% of patients (n=12). In patients where it was not possible to achieve adequate views of both kidneys (n=8), limiting technical factors were shortness of breath (SOB) (n=6), high BMI (n=2). At least one measurement of RRI was achieved in 70% of patients (n=14). However, in 9 of these patients (64.3%) the Doppler spectral traces achieved were substandard and did not meet the measurement criteria for RRI as specified in the study protocol. In 30% of patients (n=6) no usable spectral trace was achieved and it was not possible to measure RRI. SOB was noted as a technical difficulty in 60% of patients (n=12) including three for whom RRI measurements were achieved. In 9 patients (45%) SOB was recorded as the primary reason for failure to acquire a usable Doppler trace. All criteria for RRI measurements were met in only 3 patients (15%). CONCLUSION: Measurement of RRI was not feasible in patients requiring resuscitation room care using a current point of care ultrasound system. If RRI is to play a useful role in this high priority patient group, adaptation of the available technology is required to mitigate the problem of image blur due to patient breathing movement.

Presepsin (PSEP) is released during infectious diseases and can be detected in the blood. PSEP has shown promising results as sepsis marker. We examined the diagnostic and prognostic validity of PSEP in patients suspicious of sepsis on admission in the emergency department (ED). Methods One hundred twenty three patients with signs of SIRS and/or sepsis and 123 healthy individuals were enrolled. PSEP was determined on admission, after 8, 24 and 72 h. Results Mean PSEP concentrations of the control group and the patient group were 130 and 1945 pg/ml. PSEP differed between SIRS, sepsis, severe sepsis and septic shock and showed strong association with 30-day mortality ranging from 10.3% in the 1st to 32.1% in the 4th quartile. The ROC curve analyses revealed an AUC value of 0.743. Combined assessment of PSEP and MEDS score increased the AUC up to 0.878 demonstrating the close relationship with outcome. Based on the PSEP values in the different severity degrees, decision thresholds for risk stratification were established. The course of PSEP during the first 72 h was associated with effectiveness of treatment and outcome. Conclusions PSEP allowed outcome prediction already on admission to a similar degree as the clinical scores MEDS and APACHE II. Combination of PSEP with MEDS score improved the discriminatory power for outcome prediction. / Our study has been supported by Mitsubishi Chemical Europe through providing the PSEP reagents free of charge. Dr. Carpio has received speaker honoraria from Mitsubishi Chemical Europe. DIAneering – Diagnostics Engineering & Research consulted to Axis Shield Diagnostics, Mitsubishi Chemical Europe, Radiometer, Roche Diagnostics, Shanghai Kehua Bio-engineering. No potential conflict of interest to this paper was reported / Peer review

Background: Physical and verbal aggression against healthcare staff, particularly nurses is an international concern. The emergency department is seen as a high-risk area for workplace aggression. Working as a nurse in such environment is demanding and involves facing a variety of risks and threats. Aim: To highlight nurses' experiences of threatening situations at emergency departments. Method: A literature study based on qualitative articles. Eleven articles were analysed and included. Results: How the nurse experience the threatening situation defines the outcome of the consequences. The nurses' experiences can be divided into three main themes; to constantly be on your guard, unseen and unheard, vulnerable and inadequate. The feeling of fear in their working environment effected the caring of all patients. Conclusion: The experience of threatening situations is individual and can be percieved in different ways. Often a feeling of fear and insecurity emerges. The patientcare is therefore negatively affected and nurses receive little support from the hospital management. / Hotfulla situationer är ett fenomen som ökar inom samhället, vilket också återspeglas inom vården. Akutmottagningar är en plats inom sjukvården som betraktas vara ett högriskområde för hot och våld. Att arbeta som sjuksköterska på en akutmottagning gör att risken för att hamna i hotfulla situationer är stor. Hur stor förekomsten egentligen är kan vara svårdefinierad då alla händelser kanske inte alltid rapporteras. Upplevelsen i samband med hotfulla situationer kan vara individuell och uppfattas på olika sätt. Genom en litteraturbaserad studie belystes området. I studien granskades 11 kvalitativa artiklar vilket genererade i ett resultat bestående av tre teman och sju underteman. De teman som framkom var att ständigt vara på sin vakt, att inte bli sedd och hörd och att känna sig sårbar och otillräcklig. Sjuksköterskorna ansåg att de ständigt fick vara på sin vakt, då de aldrig visste när en hotfull situation kunde uppstå. När hotfulla situationer uppstod fanns det brister i stöd från verksamheten, samtidigt som avvikelserapporteringen inte skedde på ett sätt som gjorde att förekomsten kom till ledningens kännedom. Verksamheten satte in åtgärder i form av överfallslarm och säkerhetsvakter, istället för att ordna förebyggande säkerhetsåtgärder. Sjuksköterskorna ansåg att det var en brist på känslomässigt stöd från ledningen, vilket ledde till att de kände rädsla och att omvårdnaden brast när de inte ville vårda hotfulla patienter. Sjuksköterskorna upplevde att de hade det svårt att se hur de skulle kunna hantera hotfulla situationer i framtiden, de hade svårigheter att hantera sina känslor och deras privatliv påverkades negativt.

Bakgrund: Akutmottagningen är en plats dit människor söker sig vid akuta besvär, de har öppet dygnet runt, det finns inga schemalagda besök och väntetiderna är långa. Kommunikation är en viktig faktor på en akutmottagning då det används för att leverera omvårdnad och för att samarbeta. Sjuksköterskan på en akutmottagning har en hög arbetsbelastning och besitter breda kunskaper för att leverera vård till de varierande sjukdomarna som förekommer. Man vet att vara patient på ett sjukhus kan innebära ett förlorat egenvärde och hopplöshet däremot finns det lite studier på hur det är att vara patient på en akutmottagning.

Reliance on emergency departments (EDs) by economically disadvantaged people for initial cancer diagnosis in place of primary care and early diagnosis and treatment is 1 obvious plausible explanation for cancer disparities. Claims data from a safety net hospital for the years 2009–2010 were merged with hospital tumor registry data to compare hospitalizations for ED-associated initial cancer diagnoses to non–ED associated initial diagnoses. The proportion of initial cancer diagnoses associated with hospital admissions through the ED was relatively high (32%) for all safety net hospital patients, but disproportionately higher for African Americans and residents of the impoverished urban core. Use of the ED for initial diagnosis was associated with a 75% higher risk of stage 4 versus stage 1 cancer diagnosis, and a 176% higher risk of dying during the 2-year study period. Findings from this study of ED use within a safety net hospital documented profound disparities in cancer care and outcomes with major implications for monitoring disparities, Affordable Care Act impact, and safety net hospital utilization.