Bakgrund: Basala hygienrutiner ska enligt Socialstyrelsen tillämpas för att förebygga vårdrelaterade infektioner (VRI). VRI är ett hot mot patientsäkerheten och kan medföra ökat lidande för patienten och ökade kostnader för samhället. Syfte: Att undersöka följsamhet till basala hygienrutiner inom ambulanssjukvård i ett antal utvalda omvårdnadssituationer. Metod: En deskriptiv kvantitativ studie där data inhämtades genom strukturerad observation. Bekvämlighetsurval tillämpades och totalt 68 observationer gjordes på två ambulansstationer inom samma landsting. Huvudresultat: Följsamhet till basala hygienrutiner varierade, med högst följsamhet till rutinen om kort eller uppsatt hår (87%) samt till användning av handskar (87%). Lägst följsamhet observerades till rutinen om handdesinfektion före patientnära arbete eller användning av handskar (1%). Inte vid någon observation (0%) visades följsamhet till samtliga sju basala hygienrutiner som undersöktes. Slutsats: Att brister av varierande grad fanns i följsamhet till basala hygienrutiner. Särskilt stor förbättringspotential visade de basala hygienrutinerna gällande handdesinfektion före och efter patientnära arbete eller användning av handskar. Bristerna i följsamhet till basala hygienrutiner kan leda till brister i patientsäkerhet i form av en risk att patienter drabbas av VRI och ökat lidande. Orsakerna till resultatet kan troligtvis ligga både på individnivå och organisationsnivå vilket gör det särskilt angeläget att resultatet diskuteras i berörda verksamheter samt fortsatta studier. / Background: According to the Swedish National Board of Health and Welfare, compliance to hygiene routines is important to prevent healthcare-associated infections (HCAI). HCAI are a threat to patient safety and may increase patient suffering and costs for the society. Aim: To describe compliance to hygiene routines within ambulance care in a number of given situations. Method: A descriptive quantitative study with data collection through structured observation. Convenience sampling was used and 68 observations in total were made on two ambulance stations. Main result: Varying compliance to hygiene routines was found, with highest compliance to the routine stating that hair should be short or up (87%) and the routine about use of gloves (87%). The lowest compliance was found to the routine about hand disinfection before patient contact or glove use (1%). No observation showed compliance to all seven hygiene routines covered by the study. Conclusion: That compliance with hygiene routines has shortcomings, especially regarding hand disinfection, which may lead to weak patient safety through a risk of HCAI and patient suffering. The shortcomings are probably grounded both on an individual and an organisational level which makes discussion of the subject in affected organisations and further studies important.

Situated cognition argues that learning takes place in an embedded social and physical environment, and through a social process, reality takes on meaning. This dissertation investigated if a link exists between learners’ participation and advancement within a sociocultural community of practice as specifically evidenced by higher rates of tracheal intubations on live patients and scores on the national certifying examination by paramedics. During 2006, paramedic students taking the national certifying examination were asked to answer a post-examination questionnaire quantifying the number of intubations performed during training. For intubation experience, significant odds ratios (relative to none performed) were observed for 4 to 9 performed [OR = 1.66, 95% c.i. = (1.24, 2.23)] and 16 or more performed [OR = 1.76, 95% c.i. = (1.21, 2.56)]. The male to female odds ratio [OR = 1.25, 95% c.i. = (1.04, 1.52)] was significant. For age category, significant odds ratios (relative to 40 and over) were observed for 20 to 24 [OR = 1.70, 95% c.i. = (1.27, 2.28)] and 25 to 29 [OR = 1.32, 95% c.i. = (1.00, 1.73)]. For education, the bachelor’s degree to high school odds ratio [OR = 2.56. 95% c.i. = (1.95, 3.35)] was significant. For ethnicity, significant odds ratios (relative to African-Americans) were observed for whites [OR = 1.69, 95% c.i. = (1.04, 2.74)] and others [OR = 2.33, 95% c.i. = (1.15, 4.72)].The multivariable logistic regression model results suggest that the number of tracheal intubations, sex, ethnicity and education level are all associated with greater odds of passing the certifying examination. In addition to traditional classroom lectures and activities, paramedic students also learn in clinical situations with varying levels of supervision culminating in near independent practice. Theories of situated cognition provide insight into these clinical learning situations that break from traditional models. When context, content, and community merge, knowledge is generated in new and meaningful ways. By participating in communities of practice, knowledge is transferred, created, and altered along with the learner through active engagement with all the illstructured, dynamic, and unpredicted opportunities the ‘real world’ offers. The students’ exposure to live tracheal intubations during training serve as an example of situated learning environments and its influence can be observed through the national certifying examination. The findings provide guidance for paramedic educators in creating situative learning affordances and specifically, determining the number of tracheal intubations performed during paramedic training.

Emergency departments (EDs) are the only source of medical care for many adults and have been found to be feasible venues for vaccinating high-risk patients against seasonal influenza. Since the CDC guidelines expanded in 2008 to include any adults wishing to protect themselves and those around them from the flu, the vaccination of low-risk patients in the ED has not been evaluated. This study sought to assess the acceptability among adult patients of all ages for vaccinating against seasonal influenza in the Urgent Care area of an urban ED, which treats primarily healthy adults. A convenience sample of adult patients in the Urgent Care area was surveyed in November 2009. Subjects were asked about their vaccination history, as well as their perceived need and potential acceptance of a vaccine in the ED. Demographic data obtained included age, race, education, insurance status, medical history, access to primary care and contact with high-risk individuals. 381 patients were approached, of whom 352 completed the survey (92.4%; 56% male, 44% female; mean age 36 years, Standard Deviation 12.4), and 349 were vaccine-eligible. 250 (72%) denied any significant medical history. While 169 patients (48.4%) had an influenza vaccination history, only 69 (20%) were vaccinated in 2009. Of the 280 not vaccinated this year, 179 (64%) would have accepted the vaccine in the ED. Factors associated with increased odds of vaccine acceptance in the ED included: age younger than 50 years (Odds Ratio [OR] 3.28, 95% Confidence Interval [CI] = 1.74 to 6.21, p<0.01), Latino/Hispanic ethnicity (OR 2.89, 95% CI = 1.52 to 5.51, p<0.01), and close contact with high-risk individuals (OR 2.28, 95% CI = 1.33 to 3.92, p<0.01). These results suggest that the majority of relatively healthy adult patients would accept the seasonal influenza vaccine in the ED. Although a shortage of vaccines and increased vigilance during a concurrent H1N1 outbreak may have influenced overall acceptability, we conclude that influenza vaccinations during the ED patient encounter would generally be acceptable to patients as a means to improve their overall health, and indirectly the health of their high-risk close contacts.

Background “Over-crowding” in Accident and Emergency (A&E) departments of Hong Kong public hospitals with primary care cases not only threatens the service quality of emergency care and prolongs patients’ waiting time for treatment in the A&E departments, but also causes inefficient utilization of resources and deprives true emergency cases of quality care. A local study suggested that 57% of A&E attendances would have been managed better by general practitioner (GP) care. Reasons of the “over-crowding” include: lacking overnight outpatient services in the community, the convenience of A&E departments and the comprehensiveness of emergency services provided in the departments. As a result, there are urgent needs of patients, the society, A&E departments of Hong Kong public hospitals for a feasible solution to divert non-emergent A&E patients to more appropriate primary care services. Objectives To compare the costs and benefits of setting up the proposed 24-hour public emergency clinic inside the A&E department of Prince of Wales Hospital (PWH) for stable ambulatory non-emergent Categories IV and V A&E attendances by conducting a cost-benefit analysis. Methodology Retrospectively compare the costs and benefits of healthcare service provision to A&E attendances in PWH from Feb 2013 to Jan 2014 by cost-benefit analysis. By estimating the patients’ utilization rate of the emergency clinic, the total cost of the proposal is calculated by summarizing the estimated costs of employees’ salaries, capital costs, costs of equipments and treatments provided in the clinic in monetary values. The total benefit of the proposal is calculated by summarizing the estimated benefits of revenues, productivity gain from prevention of prolonged waiting and benefit from emergency diversions in monetary values. Results With the patients’ utilization rate of the clinic estimated as 44%, the total cost of the proposal is estimated as HKD $ 868,863 per month; while the total benefit is estimated as HKD $2,366,695 per month. The net benefit is estimated as HKD $1,497,832 per month with cost-benefit ratio greater than 2.72 of total benefit over total cost. Conclusions The proposal of setting up the 24-hour public emergency clinic in the A&E department of PWH is economically beneficial, and the results are generalizable to other A&E departments of similar acute urban public hospitals in Hong Kong. / published_or_final_version / Public Health / Master / Master of Public Health

PURPOSE. Domestic violence has a significant prevalence in the world, and certainly in South Africa, yet Emergency Care Practitioner (ECP) training and practice does not have any particular focus on domestic violence intervention. The absence of any clear response protocol to domestic violence in a Health Professions Council of South Africa (HPCSA) regulated profession, suggests the reliance on health practitioner discretion in this regard. This is problematic as the profession is male dominated and focused on tertiary levels of care. ECP's may be positioned to screen for abuse early, yet there is no evidence of success or failure in this endeavour. This study aimed to ascertain what the prevailing ECP knowledge, attitudes and beliefs around domestic violence in the Western Cape are, so that any factors preventing or nurturing early identification and appropriate treatment of domestic violence may be mitigated or supported respectively. METHODS. Health Professions Council of South Africa (HPCSA) registered ECP's in the Provincial Government- Western Cape (PGWC)- Emergency Medical Service (EMS) Metropole region voluntarily completed a questionnaire. MAJOR RESULTS. Only 49% of respondents could correctly define domestic violence. ECP qualification was associated with domestic violence definition in that Basic ECP's were more likely to incorrectly define domestic violence than the advanced ECP's. Eighty-one percent of respondents recognized less than thirty domestic violence calls in the preceding six months. The majority of ECP's (89%) experienced no special handling of domestic violence victims. No significant association could be found (Chi-Square: p = 0.2298) between qualification and knowledge of domestic violence laws. An ECP's qualification is no predictor of his/her legal knowledge about abuse. Qualification could also not be positively associated with the referral of victims, although the majority of practitioners of all qualifications (78%), had only sometimes referred victims or not at all. The majority of respondents expressed inadequate assessment and management of domestic violence patients. The majority also indicated that their ECP training was inadequate in preparing them for domestic violence intervention. CONCLUSIONS DRAWN. The attitudes and beliefs of Emergency Care Practitioners elicited from this study suggest a poor level of understanding of the extent and nature of domestic violence. There is a probable low detection rate amongst the majority of ECP's. There exists harbouring of myths that may confound the implementation of a pre-hospital protocol for domestic violence management. There is an inadequacy of current ECP practice with respect to domestic violence crisis intervention with regards screening, management and referral. The EMS response to domestic violence should be congruent with an appropriate health sector response and should include universal screening (asking about domestic violence routinely); comprehensive physical and psychological care for those patients who disclose abuse; a safety assessment and safety plan; the documentation of past and present incidents of abuse; the provision of information about patients rights and the domestic violence act; and referral to appropriate resources. The ECP curriculum should emphasise the particular nature and treatment of domestic violence. The study supports the need for the introduction of a comprehensive ECP protocol, in training and in practice. This information should prove useful to all who attempt to design educational programmes and clinical strategies to address this public health issue. / Thesis (M.PH.)-University of KwaZulu-Natal, 2006.

In emergency medical transport, “time to definite care” is very important. Emergency medical services and transport medicine agencies have several possible vehicle options for interfacility transfers. Use of a land vehicle, helicopter, or fixed wing aircraft will be dependent on patient condition, distance between sending and receiving hospitals, crew configuration and capabilities, and other factors such as weather and road conditions. This thesis lays out the complex process of patient transfers and highlights the challenges in decision making under time pressure; it then describes the behaviour of human operators in estimating time to definite care. To support the operators in choosing a transportation mode, a decision support tool was built, which provides relevant time estimates for interfacility transfers based on historical dispatch and call data. The goal is to enable operators to make evidence-based decisions on vehicle allocation. A prototype interface was generated and was evaluated through a usability study.

In emergency medical transport, “time to definite care” is very important. Emergency medical services and transport medicine agencies have several possible vehicle options for interfacility transfers. Use of a land vehicle, helicopter, or fixed wing aircraft will be dependent on patient condition, distance between sending and receiving hospitals, crew configuration and capabilities, and other factors such as weather and road conditions. This thesis lays out the complex process of patient transfers and highlights the challenges in decision making under time pressure; it then describes the behaviour of human operators in estimating time to definite care. To support the operators in choosing a transportation mode, a decision support tool was built, which provides relevant time estimates for interfacility transfers based on historical dispatch and call data. The goal is to enable operators to make evidence-based decisions on vehicle allocation. A prototype interface was generated and was evaluated through a usability study.

Aim: The aim of this study was to explore the attitudes and practices of the emergency staff working in the level one emergency departments in the province of KwaZulu-Natal, with regard to witnessed resuscitation. Methodology: A qualitative approach was used to explore the attitudes and practices of the staff. Two semi - structured interviews were conducted with each participant, an initial and a verifying interview, with each interview lasting between 15 - 30 minutes long. The researcher applied the principle oftheoretical saturation and a total ofsix participants from two of the four level one emergency departments were included in this study. One provincial and one private emergency department were chosen. All of the interviews were taped and transcribed prior to manual analysis, in which categories and themes were identified from the data. Findings: The emergency staff disliked the idea of witnessed resuscitation. They believed it to be a harmful experience for the witnesses, a threat to the resuscitation process, threatening for the emergency staff, and impossible to implement in their emergency departments that are already short of staff and space. Although these were their dominant feelings, there were subtle references made during the interviews that revealed that there were some aspects of witnessed resuscitation that they liked once they had considered the practice. There were no written policies to dictate how the relatives were handled, but all the staff agreed that the relatives were asked to wait outside-of the resuscitation area, they were kept informed and then brought in when the patient was stable or had died. A number of recommendations are suggested for education, practice and further research in an attempt to introduce witnessed resuscitation as an option in KwaZulu-Natal's emergency departments. / Thesis (M.Cur.)-University of Natal, Durban, 2001.

Varje år traumatiseras 200 000 barn och trauma anses vara den vanligaste orsaken till att barn söker sjukvård i Sverige. Sjuksköterskor inom akutsjukvården träffar dessa barn i sitt arbete, men de procedurer och rutiner som finns för omhändertagande av vuxna anses inte direkt vara applicerbara på barn. Syftet med denna studie var att belysa hur specialistsjuksköterskor upplever omhändertagandet av traumatiserade barn. En kvalitativ studie med individuella intervjuer (n=9) genomfördes och analyserades med hjälp av innehållsanalys. Analysen resulterade i fyra kategorier: upplevelsen av kunskapsbrist, upplevelsen av svårigheter i samband med omhändertagandet, upplevelsen av behovet av god omvårdnadskunskap och upplevelsen av skillnader i gällande rutiner. I resultatet framkom att alla intervjuade specialistsjuksköterskor upplever kunskapsbrist och har ett stort behov av att öka sina kunskaper om barn och barntrauma. Det skulle öka deras upplevelse av trygghet i yrkesrollen som specialistsjuksköterskor avsevärt. / The most common reason for children to be seek in-hospital care in Sweden is trauma and every year more than 200000 children is traumatized. Nurses meet these children in their work but the procedures used to care for traumatized adults are not transferable to children. The aim of this study was to illuminate how special educated nurses experience the caring for traumatized children. A qualitative design with one-to-one interviews (n=9) was used to collect data. Content analysis was used to analyze the data. The analysis ended up in four categories; the experience of lacking knowledge, the experience of difficulties in the care, the experience of the need of good nursing skills and the experience of differences in the routines in use. The findings show that all the interviewed nurses experience a need to increase their knowledge concerning the care for traumatized children. Increased skills and knowledge in this matter would raise their feelings of being secure in their professional role.

This study examined the effect a telephone health care information system has on emergency department patients. The research questions address the patient's acuity and the length of time between the onset of symptoms and seeking treatment.A convenience sample of 80 ambulatory emergency department patients treated over a four month period, in one emergency department of a Midwest hospital with a published telephone health care information system. The sample was divided into two groups according to the treatment. The treatment group had accessed the telephone health information system prior to emergency department visit and the control group of patients had not. The procedure for the protection of human subjects were followed.Data was collected by two instruments, a demographic questionnaire completed by the subjects, and a patient acuity scale completed by the treating emergency nurse. Acuity is scored on a 1 through 5 point scale. Subjects selected the best time interval representing the onset of symptoms and treatment. The Whitney-Mann U test was used to test differences in mean ranks. When comparing individuals who used Ask-A-Nurse, there was no significant difference between the two groups and acuity scores. There were no differences between the frequency of time interval ranges in the two groups, however a pattern indicated the subjects sought treatment sooner if the telephone health care information systems was assessed. The ability of the telephone health care information system to refer nonemergency patients to physician's offices or medical clinic and avoid overcrowded emergnecy department appears limited. Implications call for an increased method of screening and providing information to emergency patients who need health care advice. / School of Nursing