This study concerned itself with planned teaching in the hospital emergency department, that area of the hospital health care system that is becoming increasingly popular for short-term ambulatory care. However, the nursing care provided by this department has been largely unexplored by research. The purpose of this experimental study was to determine whether planned teaching involving verbal and written instructions given to a mother prior to the discharge of her child from the emergency department following treatment for a traumatic limb fracture requiring cast application, would enable her to cope more adequately with the home care of her child than the mother not receiving this planned teaching. The Null hypothesis was tested: there is no significant difference in the coping abilities of the mothers of the experimental group as compared with the mothers of the control group. Using five general hospital emergency departments, twenty mothers were assigned to alternate experimental and control groups, with the experimental subjects receiving the planned teaching before discharge. Through home visit interviews with all subjects, the mothers' coping abilities were assessed by the number of specified care objectives they had achieved. The individual totals were ranked and analyzed using the Mann-Whitney U test, the results of which led to the rejection of the Null hypothesis with p = .001, thus indicating a greater ability to cope by the mothers receiving the planned teaching. The total achievement scores of each objective were analyzed using the Fisher Exact Probability Test, resulting in five of the twenty objectives achieving significance at the .05 level. As four of the control subjects received routine written instructions before discharge from one hospital, the evaluation scores of these were compared with the remaining control subjects using the Mann-Whitney U test. No significant difference was found suggesting the ineffectiveness of written instructions without explanatory verbal instructions as well. Selected personal characteristics of the subjects and their children provided a description of the study population. The study's findings suggested that there is a lack of planned patient teaching in emergency departments although literature sources indicate that such teaching is necessary if patients and their families are to assume full responsibility for their own care. The study recommends that nurse practitioners be made aware of their teaching function and be encouraged to achieve competence and confidence in this function through inservice programs. / Applied Science, Faculty of / Nursing, School of / Graduate

EMS personnel tend to face higher burnout rates than those in similar professions, which makes them more likely to make mistakes, engage in safety-compromising behaviors, and get injured. This project examines humor used in the form of Internet memes as a coping mechanism. Internet memes are modifiable, replicable units of cultural transmission that are passed and gain influence through the Internet. I applied the Maslach Burnout Inventory to EMS related memes on the website Reddit. I found that memes that dealt with burnout typically referenced non-traumatic factors as being the source of burnout, and that these memes would often lead to conversations that allowed EMS personnel to share their experiences with one another. I concluded that internet memes can provide a way for EMS personnel to express their feelings anonymously and through a façade of humor, and can also let other people who may be going through similar experiences know that they are not alone.

京都大学 / 0048 / 新制・課程博士 / 博士(社会健康医学) / 甲第22380号 / 社医博第102号 / 新制||社||医11(附属図書館) / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 中山 健夫, 教授 小池 薫, 教授 今中 雄一 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DFAM

Simulation is a powerful technique to study complex problems and systems. This thesis explores two different problems. Part 1 (Chapters 2 and 3) focuses on the theory and practice of the problem of simulating graphs with a prescribed degree sequence. Part 2 (Chapter 4) focuses on how simulation can be useful to assess policy changes in emergency medical services (EMS) systems. In particular, and partially motivated by the COVID-19 pandemic, we build a simulation model based on New York City’s EMS system and use it to assess a change in its hospital transport policy. In Chapter 2, we study the problem of sampling uniformly from discrete or continuous product sets subject to linear constraints. This family of problems includes sampling weighted bipartite, directed, and undirected graphs with given degree sequences. We analyze two candidate distributions for sampling from the target set. The first one maximizes entropy subject to satisfying the constraints in expectation. The second one is the distribution from an exponential family that maximizes the minimum probability over the target set. Our main result gives a condition under which the maximum entropy and the max-min distributions coincide. For the discrete case, we also develop a sequential procedure that updates the maximum entropy distribution after some components have been sampled. This procedure sacrifices the uniformity of the samples in exchange for always sampling a valid point in the target set. We show that all points in the target set are sampled with positive probability, and we find a lower bound for that probability. To address the loss of uniformity, we use importance sampling weights. The quality of these weights is affected by the order in which the components are simulated. We propose an adaptive rule for this order to reduce the skewness of the weights of the sequential algorithm. We also present a monotonicity property of the max-min probability. In Chapter 3, we leverage the general results obtained in the previous chapter and apply them to the particular case of simulating bipartite or directed graphs with given degree sequences. This problem is also equivalent to the one of sampling 0–1 matrices with fixed row and column sums. In particular, the structure of the graph problem allows for a simple iterative algorithm to find the maximum entropy distribution. The sequential algorithm described previously also simplifies in this setting, and we use it in an example of an inter-bank network. In additional numerical examples, we confirm that the adaptive rule, proposed in the previous chapter, does improve the importance sampling weights of the sequential algorithm. Finally, in Chapter 4, we build and test an emergency medical services (EMS) simulation model, tailored for New York City’s EMS system. In most EMS systems, patients are transported by ambulance to the closest most appropriate hospital. However, in extreme cases, such as the COVID-19 pandemic, this policy may lead to hospital overloading, which can have detrimental effects on patients. To address this concern, we propose an optimization-based, data-driven hospital load balancing approach. The approach finds a trade-off between short transport times for patients that are not high acuity while avoiding hospital overloading. To test the new rule, we run the simulation model and use historical EMS incident data from the worst weeks of the pandemic as a model input. Our simulation indicates that 911 patient load balancing is beneficial to hospital occupancy rates and is a reasonable rule for non-critical 911 patient transports. The load balancing rule has been recently implemented in New York City’s EMS system. This work is part of a broader collaboration between Columbia University and New York City’s Fire Department.

Thesis (Master of Emergency Medical Care (MEMC))--Cape Peninsula University of Technology, 2019 / Introduction: Road traffic injuries are the ninth leading cause of death globally. Projections indicate that without new and sustained commitment globally to preventing such injuries, the situation will only worsen. Motor vehicle rescue does not lend itself to the prevention of road traffic incidents but through ensuring that all incidents are managed using sound evidence could contribute in positive outcomes for victims. It is unknown what contribution rescue education makes to the body of medical rescue knowledge in South Africa. Aims: The aim of this research was to investigate the relevance and scope of the principles of physics within medical rescue specifically in the context of motor vehicle rescue. It appears that current traditional methods of presenting rescue training, which is mainly procedural and technical, may contribute to 'segmented' learning. Research Methodology: Using an interpretive research design, multiple qualitative methodologies were employed. This methodological triangulation was intended to improve construct validity and trustworthiness of findings. A modified Delphi process through which questionnaires was repeatedly distributed to rescue experts was employed. Process tracing was used to evaluate the developed typical motor vehicle rescue case scenario narrative for underpinnings of the principles of physics. The Bachelor Emergency Medical Care Physics and Extrication subject guides was evaluated for its educational alignment during the document analysis. Legitimation Code theory as a theoretical framework was utilised to appraise the knowledge gap. Results & Discussion: Motor vehicle rescue incident may not always present in a similar manner due to various factors and influences. Development of the typical motor vehicle case narrative from which its physics principles could be identified was imperative. Most motor vehicle rescue related training occur with the vehicle in the upright orientation on all four wheels. This manner of frequent training may restrict rescue practitioners from moving beyond their 'typical' training knowledge when the situation presents a typical. The thematic document analysis of the BEMC Physics and Extrication subject guides lacked the necessary coherence which is required for a professional degree. It was deemed void of certain threshold concepts and structure which would allow the student to move between the theoretical and contextual knowledge. Motor vehicle rescue subject guides and most textbooks on the topic leaned towards a procedural and very technically detailed pedagogy, to the extent that it could contribute to segmented learning. Conclusion: Developing curricula that is underpinned by a theoretically sound evidence base would promote credibility of a qualification. Curricula by design inform the teaching, learning and the competencies which would ultimately be assessed. Professional degrees are intended to develop practitioners who would graduate with the knowledge and competencies to adapt to situations. In addition, graduate attributes of lifelong learning, reflective practice and the ability to contribute to the development of new knowledge is secondary to the goal of qualification attainment.

Bakgrund: Akutsjukvård ges till någon som blivit akut sjuk eller skadad, vården ska dessutom leva upp till samhällets krav på god och säker vård. Idag arbetar både grund- och specialistutbildade sjuksköterskor på Sveriges akutmottagningar. Teamarbete är en viktig framgångsfaktor för att öka effektiviteten av vården. Syfte: Syftet med studien var att belysa vårdpersonals erfarenheter av och reflektioner kring teamarbete inom akutsjukvård.  Metod: En litteraturstudie baserad på åtta kvalitativa studier. Artikelsökningen genomfördes i PubMed och Cinahl. Artiklarna har granskats, analyserats och sammanställts.    Resultat: Litteraturstudiens resultat presenteras i tre kategorier och åtta underkategorier; Behovet av en formell struktur: Vikten av god kommunikation, Vikten av tydliga roller och Vikten av en ledare. Hinder för ett optimalt teamarbete: Oerfarna teammedlemmar och Arbete under stress. Möjligheter som främjar teamarbetet: Skapa goda relationer, Stötta och hjälpa varandra och Utbildning och träning.  Konklusion: Fungerande teamarbete är vitalt för patientsäkerheten. Sjuksköterskor har en betydande roll i teamet samt påverkar utfallet av teamarbetet och vården. Det behövs kontinuerlig träning och utbildning i teamarbete samt riktlinjer över hur teamarbete ska bedrivas. / Background: Emergency care is given to someone who has been acutely ill or injured, the care must also live up to society’s demands for good and safe care. In Sweden both registered- and specialist nurses work in the emergency department. Teamwork is an important factor to increase efficiency of care.  Aim: The aim of this study was to illuminate health personnel’s experiences of and reflections on teamwork in the emergency medical services.  Methods: A literature study based on eight qualitative studies. Search for articles was conducted in the databases PubMed and Cinahl. Articles have been reviewed, analyzed and complied.  Results: Results of the literature study are presented in three categories and eight subcategories; Need of a formal structure: Importance of good communication, Importance of clear roles and Importance of a leader. Obstacles to optimal teamwork: Inexperienced team members and Working during stress. Options that promotes teamwork: Create good relationships, Support and help each other and Education and training.  Conclusion: Functional teamwork is vital for patient safety. Nurses have a significant role in the team and influence the outcome of teamwork and care. Continuous training and education are required as well as guidelines on how teamwork should be conducted.

Bakgrund: Arbetsrelaterad stress är en faktor som kan utlösas inom arbetet, då arbetsplatsen inte har rätt förutsättningar för vårdpersonalen. Detta är vanligt inom akutsjukvården relaterat till sjuksköterskans omvårdnadsansvar, vilket motiverar vikten av att identifiera tillvägagångssätt för att hantera detta.    Syfte: Att beskriva hur sjuksköterskor inom akutsjukvården upplever arbetsrelaterad stress och hur det hanteras.  Metod: En allmän litteraturöversikt utformades och data analyserades utifrån en tematisk analys av tio originalartiklar med kvalitativ ansats.  Resultat: Resultatet redogör kring sjuksköterskans upplevelser av stress och hantering av detta då två teman utformades; upplevelser samt strategier. Kategorier som formulerades var arbetsbelastning, hälsokonsekvenser, känslomässiga upplevelser, interprofessionellt teamarbete, god arbetsmiljö och motivation inom arbetsgruppen.   Slutsatser: Sjuksköterskan påverkas av arbetsrelaterad stress till följd av olika faktorer som exempelvis överbeläggning av patienter och tidsbrist. Detta kan hanteras utifrån problemfokuserade strategier vilket underlättar det dagliga arbetet inom akutsjukvården.   Implikationer: Författarna rekommenderar vidare forskning med avseende för att främja sjuksköterskans hälsa och en säker vård. / Background: Occupational stress is a factor that can be triggered within the work, as the workplace does not have the right conditions for the care staff. This is common in emergency care related to the nurse's responsibility, which justifies the importance of identifying approaches to dealing with this issue. Aim: To describe how nurses in emergency care experience occupational stress and how it handles.  Method: A general literature review was designed and data were analyzed based on a thematic analysis of ten original articles with a qualitative approach. Results: The results report the nurse's impact of stress and management of this where two themes were formulated; experiences and strategies. Categories that were formulated where workload, health consequences, emotional experiences, interprofessional teamwork, good work environment and motivation within the work group. Conclusion: The nurse is affected by occupational stress as a result of various factors such as overcrowding of patients and lack of time. This can be handled based on problem-focused strategies, which facilitates the daily work in the emergency care. Implications: The authors further recommend research with regards to promoting the health of nurses and safe care.

Background: Suicide has a negative impact on those bereaved by suicide. Early intervention has been shown to be beneficial. However, there is limited knowledge as to what specific kind of intervention should be offered in the immediate aftermath. Aim: To explore the experiences and demands of the suicide bereaved in the immediate aftermath of the loss of a relative due to suicide. Method: Literature study with thematic analysis. Results: In the immediate aftermath of suicide, the bereaved have a need to be acknowledged, to be able tom normalise emotions, get help in mobilizing their informal support networks, and be allowed to express anger. Furthermore, the bereaved need to be regarded and treated as in need of help and to be offered continued help without having to actively ask for and seek out help. Finally, the bereaved need information, both orally and in writing. They need psychoeducation regarding the grief process as well as information about practicalities and how to contact the health system. Conclusions: The suicide bereaved have an extensive and multifaceted need for help, support and information during the immediate aftermath of the loss of a relative due to suicide. Given the results of this study, there is reason to critically examine the current lack of routines for a structured care of the bereaved in emergency and prehospital care. / Bakgrund: Efterlevandes hälsa påverkas menligt vid suicid. Tidiga insatser till stöd för de efterlevande kan påverka förloppet, men kunskapsläget är begränsat vad gäller vilka specifika insatser som bör erbjudas i direkt anslutning till suicidiet. Syfte: Att belysa efterlevandes erfarenheter och vilket stöd de efterfrågar i direkt anslutning till förlusten av en anhörig i fullbordat suicid. Metod: Litteraturstudie med tematisk analys. Resultat: Under den första perioden efter en förlust av närstående i fullbordat suicid har efterlevande behov av att bli uppmärksammade, att få hjälp att normalisera känslor, hjälp att mobilisera det egna stödnätverket och att bli lyssnade på och få ge uttryck för sin ilska. Vidare har de efterlevande behov av att bli aktivt uppsökta, att bli betraktade och bemötta som hjälpbehövande och att bli erbjudna fortsatt hjälp utan att själva behöva be om det. Avslutningsvis har de efterlevande behov av information, såväl muntligen som i skrift. De har behov av psykoedukation beträffande sorgeprocessen men även information kring praktikaliteter och kontaktvägar i vården. Slutsatser: Efterlevande har ett stort och mångfacetterat behov av hjälp, stöd och information på flera olika plan under den första tiden efter en förlust av närstående i fullbordat suicid. Givet denna studies resultat finns anledning att kritiskt granska den rådande bristen på rutiner för ett strukturerat omhändertagande av efterlevande i akut- och prehospital vård.

Det är känt att barn inom akutsjukvården inte får adekvat smärtlindring. Detta beror dels på kunskapsluckor och att det råder en viss osäkerhet i att bedöma barns smärta och hur man ska smärtlindra barn. Dessa faktorer kan resultera i att barnet kan bli lidande. Syftet med studien var att belysa vad som främjar en optimal smärtlindring hos barn. Metoden som användes var en litteraturöversikt med systematisk ansats och en integrerad analys. Sökningar genomfördes i databaserna CINAHL och PubMed vilket resulterade i 14 artiklar. Ytterligare tre artiklar inkluderades i studien genom manuella sökningar. Totalt bygger studien på 17 artiklar av kvalitativ, kvantitativ och mixad metod. Artiklarna analyserades med hjälp av en integrerad analys och resultatet utmynnade i två huvudkategorier samt fyra underkategorier. Resultatet visade att det krävs mer utbildning till sjukvårdspersonal inom akutsjukvården för att öka deras kunskaper i att korrekt bedöma barns smärta med hjälp av smärtskattningsinstrument för att sedan kunna ge barnet adekvat smärtlindring inom en rimlig tid. Fentanyl intranasalt och Morfin intravenöst var lika effektivt hos barn som upplevde måttlig till svår smärta. Dock kan barnen gynnas av intranasala läkemedel för att undvika obehag av nålstick vid intravenös venväg. Interaktionen mellan sjukvårdspersonal, föräldrar och barn kan påverka barns upplevda smärta positivt. Barn som inte hade sin förälder närvarande upplevde högre smärta än de barn som hade en förälder vid sin sida. Slutsatsen av denna studie var att mer utbildning och kunskap för personalen behövs, med fokus på smärtbedömning och användandet av validerade smärtskattningsinstrument. Vidare bör sjukvårdspersonalen involvera föräldrar för att minska barnets smärta och ångest. / It is known that children in emergency care do not receive adequate pain relief. This is partly due to knowledge gaps and that there is some uncertainty in assessing children's pain and how to relieve children's pain. These factors can result in the child suffering. The purpose of the study was to shed light on what promotes optimal pain relief in children. The method used was a literature review with a systematic approach and an integrated analysis. Searches were performed in the CINAHL and PubMed databases, resulting in 14 articles. An additional three articles were included in the study through manual searches. In total, the study is based on 17 articles of qualitative, quantitative and mixed method. The articles were analyzed using an integrated analysis and the results resulted in two main categories and four subcategories. The results showed that more training is required for medical staff in emergency care to increase their knowledge of correctly assessing children's pain with the help of pain assessment instruments in order to then be able to give the child adequate pain relief within a reasonable time. Fentanyl intranasally and Morphine intravenously were equally effective in children who experienced moderate to severe pain. However, children can benefit from intranasal drugs to avoid the discomfort of needle sticking by intravenous venous route. The interaction between healthcare professionals, parents and children can positively affect children's perceived pain. Children who did not have their parent present experienced higher pain than the children who had a parent by their side. The conclusion of this study was that more training and knowledge for staff is needed with a focus on pain assessment and the use of validated pain assessment instruments. Furthermore, healthcare professionals should involve parents to reduce the child's pain and anxiety.

Objective: There is growing evidence that therapeutic hypothermia and other post-resuscitation care improves outcomes in out-of-hospital cardiac arrest (OHCA). Thus, transporting patients with return of spontaneous circulation (ROSC) to specialized facilities may increase survival rates. However, it is unknown whether prolonging transport to reach a designated facility would be detrimental. Methods: Data from OHCA patients treated in EMS systems that cover approximately 70% of Arizona's population were evaluated (October 2004-December 2006). We analyzed the association between transport interval (depart scene to ED arrival) and survival to hospital discharge in adult, non-traumatic OHCA patients and in the subgroup who achieved ROSC and remained comatose. Results: 1846 OHCA occurred prior to EMS arrival. Complete transport interval data were available for 1177 (63.8%) patients (study group). 253 patients (21.5%) achieved ROSC and remained comatose making them theoretically eligible for transport to specialized care. Overall, 70 patients (5.9%) survived and 43 (17.0%) comatose ROSC patients survived. Mean transport interval for the study group was 6.9 min (95% CI: 6.7, 7.1). Logistic regression revealed factors that were independently associated with survival: witnessed arrest, bystander CPR, method of CPR, initial rhythm of ventricular fibrillation, and shorter EMS response time interval. There was no significant association between transport interval and outcome in either the overall study group (OR = 1.2; 0.77, 1.8) or in the comatose, ROSC subgroup (OR 0.94; 0.51, 1.8). Conclusion: Survival was not significantly impacted by transport interval. This suggests that a modest increase in transport interval from bypassing the closest hospital en route to specialized care is safe and warrants further investigation.