Older adults, especially those who are of low socioeconomic status, experience higher rates of mortality and chronic disease. As a result, older adults are frequent users of emergency medical service (EMS), comprising approximately 38-48% of all EMS calls. In response to higher EMS demands, community paramedicine has recently emerged as a non-traditional model whereby paramedics provide care in a community- based setting. CP@clinic is a community paramedicine programme that focuses on disease prevention and health promotion with the goal of reducing EMS demand. Given the knowledge that older adults who live in subsidized housing have poorer health outcomes, CP@clinic has been implemented in several subsidized housing building across Ontario. A program evaluation of CP@clinic is currently underway to make recommendations to paramedic partner stakeholders regarding program delivery. As part of this evaluation, I sought to understand the association of the number of CP@clinic sessions held per month and EMS calls per apartment unit. De-identified EMS call data were collated from 9 paramedic services across Ontario from February 2015 to December 2019. I conducted a three-level multilevel regression analysis, with EMS calls per apartment unit as the outcome. The primary analysis found that a one-session increase in the number of sessions held per month was associated with an average 2.4% higher incident rate of EMS calls, adjusted for building size. A secondary analysis, with the number of sessions per month as a categorical variable, revealed that two CP@clinic sessions per month had the smallest association with EMS calls, adjusted for building size. Based on these results, it is recommended that paramedic services offer two or more CP@clinic sessions per month. Future research should investigate the factors that impact each services’ ability to offer the CP@clinic programme. / Thesis / Master of Science (MSc) / Older adults experience high rates of chronic diseases, especially older adults living in subsidized housing. Community paramedicine has recently emerged as a way of addressing the healthcare needs of older adults living in subsidized housing, while simultaneously decreasing the burden on EMS. CP@clinic is a community paramedicine programme aimed at improving the health of older adults and reducing the demand on EMS. To make recommendations to the paramedic services operating CP@clinic, I sought to understand the association between the frequency of CP@clinic sessions and the number of EMS calls per apartment unit in Ontario. Based on the results, CP@clinic sessions were associated with higher incident rate of EMS calls, after accounting for building size, reflecting the trend of rising EMS calls in Ontario. Overall, paramedic services may see improved EMS call outcomes with two or more CP@clinic sessions per month but should offer the programme according to their organizational capacity.

The first chapter of this thesis is centered around a simple problem: to do or not to do something. As in life, every decision has an unknown outcome and planning agents try to balance the trade offs of such decision based on some relevant information. After processing the relevant information a decision is reached. In this chapter, the problem is formalized and parameterized in two frameworks: In the first framework discrete decision models known as decision trees are studied, where we design an optimization algorithm to solve the misclassification cost problem in this family of representations; The second framework studies continuously differentiable models (such as logistic regression and Deep Neural Networks) where we propose a two-step optimization procedure of the misclassification cost problem, as well as characterizing the statistical estimation problem relative to the sample size used for training. We illustrate the methodology by developing a computerized scheme to administer (or not) a preventive intervention to patients arriving to the hospital with the objective of minimizing their risk of acquiring a Hospital Acquired Infection (HAI). The second chapter expands on the idea of the first one to a sequential setting. The problem is framed as a Markov Decision Process algorithm using a state aggregation strategy based on Decision Trees. These incremental state aggregations are solved using a Linear Programming (LP) approach to obtain a compact policy that converges to the optimal one asymptotically, as well as showing that the computational complexity of our algorithm depends on the tree structure of the optimal policy rather than the cardinality of the state space. We illustrate the advantages of our approach using the widely known cartpole balancing environment against a Deep Neural Network based approach showing that with a similar computational complexity our algorithm performs better in certain instances of MDP. In the last two chapters we deal with modeling Emergency Medical Service (EMS) optimization such that the demand for medical services is met with the best possible supply allocation in the face of uncertainty of the demand in space and time. In the third chapter we develop a short-term prediction model for call volume at a 911 call center. The rationale of the model is to use the recent call volume to update a historically calibrated model of the call volume that in periods when the call volume distribution drastically changes, can be arbitrarily distant from its expected value. The model is casted as a linear correction of the historical estimation, calculating both the mean and variance of the correction. We justify the formulation using a regime switching doubly stochastic process framework to illustrate the type of distribution changes our model captures. We also propose a staffing model to preemptively staff a call center using our volume prediction as input for the call center demand such that the waiting times of the customers are minimized. This formulation can be casted as a Second Order Cone Program (SOCP) or a Linear Program (LP) with integrality constraints. We illustrate the methodology to predict the call volume during the Covid-19 pandemic to a 911 call center in New York City. In the fourth chapter we modify a well known set covering formulation to perform ambulance scheduling such that the supply of ambulances matches the demand in space and time. We enhance this model using a high resolution simulation model to correct an unknown steady-state service rate of the system (dependent on many exogenous and endogenous factors such as the ambulance dispatch policy and time-varying traffic patterns) as a constraint in the scheduling formulation. We show that this formulation effectively makes the system faster by maximizing the minimum slack between supply and demand during a 24-hour period. We present an algorithm to iteratively solve the scheduling formulation while correcting the implied location and time dependent service rate of the ambulance system using the simulation generated ambulance waiting times of patients in the city. We illustrate our algorithm to schedule municipally managed ambulances in New York City as a case study.

Att möta patienter med smärta ingår i ambulanssjuksköterskans vardag. Smärta hos patienterna kan uppkomma av olika anledningar, i flera fall på grund av trauma som resulterar i smärta för patienterna. Olika metoder för att lindra smärtan hos dessa patienter finns både genom omvårdnad och medicinsk vård. Smärtlindrande läkemedel finns i olika former med varierande effekt, latenstid samt biverkningar. Australien har sedan 70-talet använt sig av lågdos metoxifluran för att lindra smärta. Läkemedlet introducerades nyligen i Sverige och skiljer sig från andra smärtlindrande läkemedel genom att det inhaleras och dosen styrs av patienten själv.  Syftet var att undersöka patientnyttan av behandling med lågdos metoxifluran hos patienter med akut måttlig till svår smärta. Metoden som har används är en litteraturöversikt med systematisk ansats där fjorton artiklar ligger till grund för att undersöka patientnyttan med lågdos metoxifluran. Sökningarna efter vetenskapliga artiklar har gjorts i databaserna PubMed samt CINAHL. Samtliga artiklar har granskats med hjälp av en kvalitetsgranskningsmall rekommenderad av Sophiahemmets Högskola. De 14 vetenskapliga artiklarna analyserades genom en integrerad analys och resulterade i tre teman och sju underteman. Resultatet visar på flertalet positiva effekter i användandet av lågdos metoxifluran. Däribland tiden till administrering och smärtlindring, god smärtlindrande effekt samt metoxiflurans minimala påverkan på vitalparametrar. Vissa negativa effekter framkom också i resultatet där många biverkningar kunde ses, samt varierande smärtlindrande effekt beroende på ålder. Slutsatsen är att lågdos metoxifluran är ett läkemedel med positiva effekter för patienter med smärta samt ett gott komplement till traditionella smärtlindrande läkemedel i Sverige. Genom kombinationen av god personcentrerad medicinering och personcentrerad omvårdnad kan ambulanssjuksköterskan individanpassa vården i komplexa miljöer. / Meeting patients in pain is part of the ambulance nurse's everyday life. Pain in the patients can arise for various reasons, but in several cases due to trauma that results in pain for the patients. Different methods to relieve the pain in these patients are available both through nursing and medical care. Pain-relieving drugs are available in different forms with varying effects, latency, and side effects. Australia has used low dose methoxyflurane to relieve pain since the 1970’s. The drug was recently introduced in Sweden and differs from other painrelieving drugs in that it is inhaled, and the dose is controlled by the patient himself. The aim of was to investigate the patient benefit of treatment with low dose methoxyflurane in patients with acute moderate to severe pain. The method that has been used is a literature review with a systematic approach where fourteen articles form the basis for investigating the patient benefits of low dose methoxyflurane. The searches for scientific articles have been made in the databases PubMed and CINAHL. All articles have been reviewed using a quality review template recommended by Sophiahemmet University. The 14 scientific articles were analyzed through an integrated analysis and resulted in three themes and seven under themes. The results show most positive effects in the use of low dose methoxyflurane. Including rapid administration and pain relief, good pain relief effect and methoxyflurane's minimal impact on vital parameters. Some negative effects also appeared in the results, where many side effects could be seen as well as varying pain-relieving effects depending on age. The conclusion is that low dose methoxyflurane is a drug with positive effects for patients with pain and a good complement to traditional pain-relieving drugs in Sweden. Through the combination of good person-centred medication and person-centred care, the ambulance nurse can individually adapt care in complex environments.

Traumapatienter med allvarliga eller livshotande skador omhändertas ofta inom akutsjukvården. Vid akut traumaomhändertagande arbetar traumateamet strukturerat, automatiserat och multiprofessionellt nära patienten. Kunskap om vuxna patienters upplevelser av akut omhändertagande vid trauma är begränsat. Det är viktigt att öka sjuksköterskors kunskap om patienters upplevelser vid akut omhändertagande vid trauma, för att få förståelse om hur de kan få sina fysiska, psykosociala och relationella behov tillgodosedda. Sjuksköterskan behöver integrera vårdande handlingar för att patienterna skall känna sig omhändertagna och uppleva god vårdkvalitet och därmed minska deras lidande. Syftet var att undersöka vuxna patienters upplevelser av akut omhändertagande vid trauma. Metoden var en allmän litteraturöversikt med en systematisk ansats. Datainsamlingen utfördes på två databaser, CINAHL och PubMed. Sammanlagt inkluderades 14 kvalitativa artiklar och en kvantitativ artikel publicerade mellan år 2012–2022 som analyserades med en integrerad metod. I resultatet identifierades tre huvudkategorier och åtta underkategorier. Underkategorierna identifierades med stöd utifrån Fundamentals of Care mellersta dimension. Resultatet visade att huvudkategorierna; fysiska, psykosociala och relationella upplevelser var både positiva och negativa. Under de fysiska upplevelserna identifierades underkategorierna; rörelse och smärta, där patienter upplevde bristfällig smärtlindring och obehag av immobilisering, men även god smärtlindring och känsla av skydd. Under de psykosociala upplevelserna identifierades underkategorierna; kommunikation som kunde vara bristfällig, delaktighet och information med mest negativa upplevelser, värdighet och respekt och emotionella reaktioner innehöll både positiva och negativa upplevelser. Under de relationella upplevelserna identifierades underkategorierna; trygghet genom empati och medkänsla, trygghet genom engagemang och trygghet genom närvaro och stöd, där det var mer jämn fördelning av negativa och positiva upplevelser. Slutsatsen av litteraturöversikten var att patienternas upplevelser av akut omhändertagande vid trauma kunde vara både positiva och negativa för patienterna. Detta ställer höga krav på att öka sjuksköterskors förståelse och kunskap om patienters upplevelser och erfarenheter av den upplevda situationen. / Trauma patients with serious or life-threatening injuries are often cared for in Emergency Medical Services. In acute trauma care, the multiprofessional trauma team works structured close to the patient. Knowledge of patients' experiences of acute trauma care is limited. It is important to increase nurses' knowledge of trauma patients' experiences of acute trauma care in order to gain an understanding of how trauma patients can have their physical, psychosocial and relational needs met. Nurses need to integrate caring actions in order for the patients to feel cared for and experience good quality of care and thereby reducing their suffering. The aim was to describe adult patients' experiences of acute trauma care. The method of the study was a general literature review with a systematic approach. Data collection was carried out in two databases; CINAHL and PubMed. A total of 14 qualitative articles and one quantitative article published between the years 2012–2022 was included and analyzed using an integrated method. In the results three main categories and eight subcategories were identified. The subcategories were identified with support based on the middle dimension of The Fundamentals of Care Framework. The results showed that under the main categories; physical, psychosocial and relational experiences were both positive and negative. Under physical experiences, the subcategories identified were; mobility and pain, where patients experienced discomfort from immobilization and inadequate pain relief, but also a sense of protection and adequate pain relief. Under psychosocial experiences, the subcategories identified were; communication that could be deficient, being involved and informed with most negative experiences, dignity and respect and emotional reactions contained both positive and negative experiences. Under the identified subcategories of relational experiences; feeling safe through empathy and compassion, feeling safe through commitment and feeling safe through presence and support, there was a more even distribution of negative and positive experiences. The conclusion of the literature review was that the patients` experiences of acute care in trauma could be both positive and negative for the patients. This put high demands on increasing nurses' understanding and knowledge of patients' experiences of the perceived situation.

Bedömning av patientens vitalparametrar (andningsfrekvens, blodtryck, puls, kroppstemperatur, saturation och medvetandegrad) är sjuksköterskans ansvar inom den akuta vårdkedjan. Tidigare forskning visar att en tidig identifiering av försämrade patienter minskar både mortalitet och morbiditet. För patientens välmående och säkerhet är det av högsta vikt att sjuksköterskor utför evidensbaserade och säkra bedömningar för att upprätthålla patientsäkerheten. Syftet var att utforska faktorer som påverkar sjuksköterskans bedömning av vitalparametrar för att tidigt upptäcka en försämrad patient inom den intrahospitala akuta vårdkedjan.  En litteraturöversikt med systematisk artikelsökning användes som metod. Databassökningar utfördes i PubMed och CINAHL. Sexton originalartiklar som undersökte sjuksköterskors bedömning av patientens vitalparametrar i den akuta vårdkedjan valdes ut från databassökningen samt manuell sökning. Studierna kvalitetsgranskades för att sedan analyseras med hjälp av integrerad analys.  Resultatet visade att sjuksköterskors bedömning av vitalparametrar påverkades av sjuksköterskefaktorer, patientfaktorer samt organisatoriska faktorer. Sjuksköterskefaktorer som sågs påverka var sjuksköterskans förhållningssätt till vitalparametrar, bedömning av frekvens, kunskap och erfarenhet, intuition, helhetsbild samt avsteg från rutiner. Gällande patientfaktorer sågs specifika patientgrupper svårare att bedöma på grund av exempelvis underliggande grundsjukdomar eller ålder. Organisatoriska faktorer som sågs påverka bedömningen var arbetsmiljö, samarbete/kommunikation, kontinuitet i vården samt bedömningsinstrument.   Slutsats som dras är att sjuksköterskans bedömning av vitalparametrar för att tidigt upptäcka en försämrad patient inom den akuta vårdkedjan är ett komplext ämne som påverkas av både sjuksköterske-, patient-, och organisatoriska faktorer. Även då vitalparametrar är ett viktigt redskap för att upptäcka förändring i patientens tillstånd och således främja patientens välmående och säkerhet, använder inte sjuksköterskans alltid dessa verktyg. Denna studie gav inte några säkra förklaringar till varför detta fenomen förekom utan behöver studeras vidare. / Assessing the patient's vital signs (respiratory rate, blood pressure, pulse, body temperature, saturation, and level of consciousness) is a responsibility assigned to the registered nurse within the emergency care chain. Previous research has shown that early identification of deteriorating patients reduces both mortality and morbidity. To enhance patient safety and well-being, it is vital that the registered nurse performs evidence-based and secure assessments of the patient.  The aim of this study was to explore the factors that influence the nurse’s assessments of vital signs to early detect patient deterioration within emergency care.   The research method used was a literature review with a systematic approach, using database searches in PubMed and CINAHL. Sixteen original articles with the main focus of examining registered nurses’ assessments of vital signs within emergency care was chosen from the database searches and manual searches. The quality of the studies was then examined, and an integrated analysis was performed.  The result of the analysis show that assessment of vital signs performed by registered nurses was affected by factors contributed to the nurse, the patient, and the organization as a whole.  When it comes to the factors found contributed to affect the registered nurses, these factors were found to be, approach to vital signs, assessment of frequency, knowledge and experience, intuition, comprehensive picture, and deviations from the established routine. For the factors contributed by the patient, specific patient groups were regarded as more difficult to assess due to underlying diseases or age.  The organisational factors seen affecting the nursing assessment were the work environment, teamwork/communication, continuity in the care and the evaluation tools at hand.  In conclusion, the results show that this is a complex subject that is affected by several factors contributed to the registered nurse, patient, and the organization. Even though vital signs are an important tool to identify changes in a patient’s well-being and safety, the registered nurse does not always utilize this as a tool. This study could not conclude any clear explanation as to why assessing vital signs was not used more often and will require further studies and analysis to determine an answer.

God kommunikation är kvalitetssäkring av god vård. Vid patientöverlämning prövas kommunikationen och det föreligger risk att information faller bort eller tolkas olika. Det har visats i tidigare studier att vårdskador uppkommit på grund av bristande kommunikation och att inom akutsjukvården är risken än högre för patientsäkerhetsincidenter. Med hjälp av olika kommunikationsverktyg har svensk sjukvård eftersträvat att öka patientsäkerheten vid överlämnande av patient, varav det mest vedertagna är SBAR som står för Situation, Bakgrund, Aktuellt och Rekommendation. Syftet med denna studie var att beskriva hur kommunikationsverktyget SBAR påverkar patientsäkerheten vid överlämnandet av patient inom akutsjukvården. Metoden för studien var en litteraturöversikt med en systematisk ansats med både kvantitativ och kvalitativ design. Litteratursökning utfördes systematiskt i databaserna CINAHL och PubMed och data analyserades utifrån Bettany-Saltikov och McSherrys standardiserade integrerade analysmetod. Resultatet presenterades i tre kategorier vilka var: Kvalitativ överlämning med SBAR, Patientsäkerheten ökade med SBAR och Överlämningstiden förlängdes utan att påverka patientsäkerheten. Samt två underkategorier: SBAR ökade kvaliteten på patientöverlämningen och Strukturen påverkade patientöverlämningens kvalitet. SBAR gav en förbättrad och mer patientsäker patientöverlämning men överlämningsstrukturen påverkades både positivt och negativt samt tidsåtgången för patientöverlämnandet ökade.  Studiens slutsats var att SBAR i stor utsträckning ökade patientsäkerheten genom att ge en mer kvalitativ patientöverlämning och genom att förbättra mätbara och upplevda patientsäkerhetsaspekter. Likväl gav SBAR också viss negativ påverkan på patientsäkerheten. / Good communication is quality assurance of good care. During patient handover communication is tested and there is a risk that information is lost or interpreted differently. It has been shown in previous studies that healthcare injuries occur due to a lack of communication and that in emergency healthcare the risk is even higher for patient safety incidents. With the help of various communication tools Swedish healthcare has strived to increase patient safety when handing over patients, of which the most accepted is SBAR which stands for Situation, Background, Assessment and Recommendation. The purpose of this study was to describe how the communication tool SBAR affects patientsafety during the handover of patients in emergency healthcare. The method for the study was a literature review with a systematic approach with both quantitative and qualitative design. A literature research was systematically performed in the CINAHL and PubMed databases and the data were analyzed based on Bettany-Saltikov and McSherry's standardized integrated analysis method. The results were presented in three categories which were: Qualitative handover with SBAR, Patient safety increased with SBAR and Handover-time was extended without affecting patient safety. As well as two subcategories: SBAR increased the quality of patient handover and Structure affected the quality of patient handover. SBAR provided an improved and more patient-safe patient handover but the handover structure was affected both positively and negatively and the time required for patient handover increased. The study's conclusion was that SBAR increased patient safety to a large extent by providing a more qualitative patient handover and through measurable and perceived patient safety aspects. Nevertheless SBAR also had some negative impact on patient safety.

Lethality of aggravated assaults has long been discussed in terms of weapons used, location of assault, demographics of victims, and regions of the US in which the assault occurred. However, dating back to the 1950s, medical response times have been discussed as a mediating factor, but minimally explored in analyses. The current study assesses the lethality of shootings with a primary focus on emergency medical and police response times in New Orleans, LA. Along with routine activities and social disorganization indicators, 102 shootings that occurred in 3 months are analyzed to establish response time patterns of lethality. Results indicate that neither medical nor police response times impact the odds of a victim surviving a shooting, but instead, it is the days on which the violent encounters occur and the socioeconomic characteristics of the neighborhood that have a stronger influence on life or death, although not statistically significant. Limitations and future research directions are discussed.

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