Acknowledgements First and foremost, I am very grateful to my supervisor, Dr. Kerstin de Wit, for her mentorship and guidance throughout my time as a graduate student. It has been a pleasure to work with someone so innovative and passionate about clinical research. Her ability to bridge thrombosis and emergency medicine research to improve and change clinical practice is inspiring. I am grateful to my supervisory committee members, Dr. Teresa Chan, Dr. Lori-Ann Linkins, and Dr. Mathew Mercuri, for their continuous support throughout this process. Our scientific discussions were always insightful, and motivated me to push myself as a researcher. I am very thankful to the entire EMeRGE Research Group for creating such a helpful and friendly environment. Their diligence and commitment to conducting high-quality research motivated me to do the same, and greatly expanded my knowledge on clinical research. Working with this team made my experience as a graduate student very memorable. I would like to thank my family and friends for all of the support they gave me throughout this entire process. Their constant encouragement and emotional support helped me overcome challenges and persevere, for which I am infinitely grateful. / Background: There is an evidence-practice gap between guidelines for diagnosing pulmonary embolism (PE) and emergency physician practice. This is concerning because computed tomography (CT) scanning is being overused to exclude PE in the emergency department (ED). It is possible that the answer behind this lies within the physician-patient relationship. Past research on shared decision-making strategies have shown to decrease use of hospital resources, and improve patient outcomes. Objective: The aim of this three-part MSc thesis was to achieve a patient-centered approach to the testing of PE in the ED. Method: 1) A systematic review on existing shared decision-making models used for testing and/or treatment of medical decisions in the ED was conducted. 2) Qualitative interviews with ED patients being tested for PE identified patient-specific values and preferences which may present as barriers to patient-centered care in the ED. 3) Both the systematic review and patient interviews informed the development of a new shared information tool to be used in the ED. Results: The systematic review found that shared decision-making interventions in ED patients tested for acute coronary syndrome and clinically-important traumatic brain injuries can potentially reduce hospital admissions and increase discharge rates without negatively affecting health outcomes. The qualitative interviews highlighted four major themes: 1) patient satisfaction comes from addressing their primary concern; 2) preference for imaging over clinical examination; 3) patients expect 100% certainty when given a diagnosis; and 4) patients expect individualized care throughout their entire ED visit. This data led to the formation of a shared information sheet which ensures that testing decisions for low-risk PE patients align with patient-specific values. Conclusion: By placing the focus on patient-centered care, this study incorporates evidence-based medicine with patient priorities in order to improve patient outcomes in the ED. / Thesis / Master of Science (MSc) / Pulmonary embolism occurs when blood clots form in veins of the legs, and travel to the lungs, causing chest pain and shortness of breath. There are well-established, evidence-based guidelines on how to diagnose pulmonary embolism. Diagnostic tools such as the Wells score and D-dimer have been proven to be safe and effective in ruling out pulmonary embolism in low risk patients preventing the need for a CT scan. However, CT scans are still being overused to diagnose pulmonary embolism in low risk patients. Unnecessary testing in the emergency department (ED) exposes patients to the harms associated with CT scanning: such as increased risk of cancer, and diagnosing blood clots that are not actually there, resulting in unnecessary treatment. It is possible that the answer behind the over-testing of PE in the ED lies within the physician-patient relationship. This three-part study first reviewed all prior studies on shared decision-making strategies, which are techniques used to help physician align medical decisions with patient-specific values, in the ED. Second, we employed qualitative methods to identify patient-specific values and preferences on PE testing in the ED. Finally, both of these aims informed the development of a patient-centered shared information tool to overcome barriers to patient-centered care. Ultimately, the goal of this study is to achieve a patient-centered approach to the testing of pulmonary embolism in the ED.

Yes / The Biochemistry and Haematology Outcome Model (BHOM) relies on the results from routine index blood tests to predict the patient risk of death. We aimed to externally validate the BHOM model. Method We considered all emergency adult medical patients who were discharged from Northern Lincolnshire and Goole (NLAG) hospital in 2014. We compared patient characteristics between NLAG (the validation sample) and the hospital where BHOM was developed. We evaluated the predictive performance, according to discriminative ability (with a concordance statistic, c), and calibration (agreement between observed and predicted risk). Result There were 29 834 emergency discharges of which 24 696 (83%) had complete data. In comparison with the development sample, the NLAG sample was similar in age, blood test results, but experienced a lower mortality (4.7% vs 8.7%). When applied to NLAG, the BHOM model had good discrimination (c-statistic 0.83 [95% CI 0.823 - 0.842]). Calibration was good overall, although the BHOM model overpredicted for lowest (<5%, observed = 229,predicted =286) and highest (≥50%, observed = 31, predicted = 49) risk groups, even after recalibrating for the differences in baseline risk of death. Conclusion Differences in patient case-mix profile and baseline risk of death need to be considered before the BHOM model can be used in another hospital. After re-calibrating for the baseline difference in risk the BHOM model had good discrimination but less adequate calibration.

Source: Masters Abstracts International, Volume: 46-01, page: 0311. Adviser: Carl Hacker. Includes bibliographical references.

<p><strong>Background and Objectives</strong>: Tools designed for systems analysis (SA) can link the different levels of healthcare by modeling the interacting, interrelated and interdependent components. The objective of this thesis was to investigate the use of discrete event simulation (DES) to help inform decision making.</p> <p><strong>Methods</strong>:</p> <p>Project 1: A new method is developed in which physicians and their delegates are modeled using DES as interacting pseudo-agents when simulating a hospital emergency department (ED).</p> <p>Project 2: Using a SA approach, we examined the referral patterns, healthcare utilization, time intervals and patient flow to identify rate limiting steps that may lead to delayed surgical candidacy and epilepsy surgery at the Hospital for Sick Children (SickKids) in Toronto, Ontario.</p> <p>Project 3: A DES model was developed of the surgical evaluation and surgery process and its associated constraints at SickKids to inform decision making at both the institutional and provincial levels. Once validated, the model was used to evaluate the effect of alternative resource capacities on waiting times.</p> <p><strong>Results:</strong></p> <p>Project 1: Neglecting the interaction between physician and delegates in the ED could result in misleading conclusions with respect to physician utilization and waiting times.</p> <p>Project 2: We found that only 5.7% of the eligible population was referred annually for surgical evaluation and that children waited on average 1-2 years for surgery. Through mapping of patient flow and resource utilization we were able to identify multiple barriers to surgery.</p> <p>Project 3: The findings support the recommendations to the province by directing requested funds to identified resources that would decrease waiting times.</p> <p><strong>Conclusions: </strong>SA tools can be used to make decisions that are generalizable to all levels of healthcare. Adopting the use of these tools increases the uptake of evidence in decision making and provides useful and critical information to develop comprehensive policies for improved healthcare.</p> / Doctor of Philosophy (PhD)

Thesis (M.Tech.: Emergency Medical Care)-Dept. of Emergency Medical Care and Rescue, Durban University of Technology, 2008. xii, 301 leaves, Annexures A-0 to A-7 / Paramedic clinical decision making (CDM) surrounding emergency airway management of the critically ill or injured patient in the pre-hospital environment is poorly understood. In order to deliver pre-hospital care effectively it is necessary to understand how paramedics make clinical decisions in this area and determine what influences clinical practice. This study primarily investigated the factors influencing paramedic CDM in the context of advanced emergency airway management with specific focus on the newly introduced skill of rapid sequence intubation (RSI). An evaluation of the correct application of RSI guidelines, the determination of the need for their review and the identification of measures to enhance CDM around RSI were secondary research questions.

UA Open Access Publishing Fund / Introduction: Language and cultural barriers are detriments to quality health care. In acute medical settings, these barriers are more pronounced, which can lead to poor patient outcomes. Materials and methods: We implemented a longitudinal Spanish-language immersion curriculum for emergency medicine (EM) resident physicians. This curriculum includes language and cultural instruction, and is integrated into the weekly EM didactic conference, longitudinal over the entire 3-year residency program. Language proficiency was assessed at baseline and annually on the Interagency Language Roundtable (ILR) scale, via an oral exam conducted by the same trained examiner each time. The objective of the curriculum was improvement of resident language skills to ILR level 1+ by year 3. Significance was evaluated through repeatedmeasures analysis of variance. Results: The curriculum was launched in July 2010 and followed through June 2012 (n=16). After 1 year, 38% had improved over one ILR level, with 50% achieving ILR 1+ or above. After year 2, 100% had improved over one level, with 90% achieving the objective level of ILR 1+. Mean ILR improved significantly from baseline, year 1, and year 2 (F=55, df =1; P,0.001). Conclusion: Implementation of a longitudinal, integrated Spanish-immersion curriculum is feasible and improves language skills in EM residents. The curriculum improved EM-resident language proficiency above the goal in just 2 years. Further studies will focus on the effect of language acquisition on patient care in acute settings

BACKGROUND: Delirium is an “acute change in cognition” prevalent in the elderly population (9). It is a clinical diagnosis which results from complex relationships between patient vulnerability and precipitating medical factors (2,9). Delirium has a complex relationship with dementia and often these two cognitive impairments occur together. While delirium occurrence is exceptionally high in dementia patients, it’s recognition by physicians is unfortunately low (10). Delirium prevalence in dementia patients can be as high as 80% and failure to recognize occurs in as many as 75% of cases (10). Recognition of delirium is important due to its association with poor outcomes and potential for prevention by avoiding precipitating causes. Common poor outcomes associated with delirium include, prolonged cognitive and physical impairment, longer hospital stays, institutionalization and death. With the increasing aging population and the rising cost of healthcare in the United States more attention has been focused on better detection of costly conditions including delirium. Efforts have been made to develop tools for universal screening to aid in the recognition of delirium; however, these are not widely used outside of research. One of the challenges in recognizing delirium is that providers lack knowledge of the patient’s baseline cognitive status, making it difficult to determine whether an acute change has occurred. Caregivers are an untapped resource, holding this key piece of information, in the early recognition of delirium. SPECIFIC AIMS: The goal of this study is to build an argument for the implementation of a training program which would teach caregivers to complete the Family Confusion Assessment method (FAM-CAM) interviews on their loved ones at home in an effort to aid in the early recognition of delirium. This will be accomplished through the followings specific aims. Aim 1: Complete a comprehensive literature review to assess the need for family based screening for delirium. An attempt will be made to identify a gap in the literature for efficient and effective delirium screening and utilization of family caregivers. Aim 2: Data collected in a completed prospective observational study “Family Member Identification of Delirium in the Emergency Department” will be analyzed to assess family caregivers’ role in recognition of delirium, and family caregivers’ receptiveness and interest in a training program. METHODS: The information in this thesis used to build the argument for FAM-CAM training was found through a comprehensive review of published literature on delirium. Resources were found mainly through Pub Med and the Hospital Elder Life Program’s Delirium Bibliography. The study; “Family Member Identification of Delirium in the Emergency Department” enrolled 63 patients for CAM only and 108 Dyads for CAM and FAM-CAM with a total N of 171. RESULTS: Results showed that in 60% of cases of delirium that were recognized by physicians, a caregiver was present and provided information on the patient. Without being made aware of potential benefits of FAM-CAM training, 34% of caregivers reported that training on the instrument would be helpful, and 46% showed interest in participating in the training. Concurrent with current research a high percentage of patients with history of dementia were found to be delirious, further exemplifying the link of risk between these two conditions and identifying caregivers of dementia patients as a good population to implement FAM-CAM training. DISCUSSION: This literature review and accompanying study data suggests that, if implemented, FAM-CAM training could lead to potential future benefits including, reduced delirium associated healthcare cost, improved patient outcomes, and an improved experience for caregivers.

Thesis (Master of Emergency Medical Care)--Cape Peninsula University of Technology, 2018. / Physical injury is a major cause of premature death and disability worldwide (WHO, 2015). Mortality statistics for South Africa indicate that approximately half of all injury-related deaths were intentionally inflicted, often as a result of sharp-force injuries (Donson 2009). Cape Town is reputed to be a violent city (Nicol et al., 2014). Pre-hospital emergency care providers are often the first medical contact for injured patients. Previously, it was understood that high volume crystalloid administration would improve survival and was standardised in the management of shock (Santry & Alam 2010). However, over-administration of crystalloid fluid can cause patient harm by potentially worsening injuries and can be detrimental to a patients survival. Current evidence supports the practice of lower volume crystalloid intravenous fluid administration- permissive hypotension. Little is known about pre-hospital emergency care providers intravenous fluid management practices for penetrating injury. Injury surveillance data for victims of penetrating injury is also scarce with the majority of current data taken from mortality sources. Surveilling pre-hospital cases may yield opportunities for prevention from premature mortality and morbidity. The aim of this study is to undertake surveillance of penetrating injury and related intravenous fluid resuscitation in the pre-hospital emergency care environment. A prospective observational descriptive survey was conducted in the Cape Metropole1. Over three consecutive months, emergency care providers documented parameters related to mechanism of injury, scene vital signs, hospital vital signs, intravenous fluid resuscitation and basic patient demographic information for patients with penetrating injury. A predetermined inclusion and exclusion criteria was used to sample patients.

Knowledge is a critical element for the provision of quality health care. Optimal clinical decision making incorporates multiple types of knowledge including patient knowledge, clinical experiential knowledge and research knowledge. Understanding how knowledge is shared and used in best practice is challenging as a number of factors can facilitate or impede the process. Several authors have highlighted the value of using a theoretical framework when examining knowledge in health care. A theoretical framework provides direction for the generation and testing of hypotheses which can contribute to building a comprehensive body of knowledge in a field of study. Although the majority of knowledge exchanged in practice settings occurs between clinicians, current knowledge exchange and utilization models in health care generally focus specifically on the exchange of research knowledge between the scientific community and the practice community. Acknowledging and understanding the knowledge seeking and sharing behaviours of clinicians is a key element in the larger knowledge translation puzzle. Emergency medicine is a clinical speciality where there is evidence of a knowledge to practice gap, however, there is limited understanding of the factors that contribute to the gap. Emergency practitioners must make decisions in a busy and often chaotic environment that is prone to multiple interruptions and distractions. The challenge for consistent and quality care is also more pronounced in rural and some suburban areas where emergency care needs are similar but resources are limited. The purpose of this program of research is to identify factors relevant to knowledge exchange and utilization in rural and urban emergency departments with the aim of developing a Model for Knowledge Exchange and Utilization in Emergency Practice. A series of studies were carried out using a mixed method research design to further develop and describe 3 key dimensions (individual, context of practice, knowledge) which were identified through a review of the literature. Data was collected using surveys, participant observations and interviews with nurses and physicians working in rural and urban emergency departments in Nova Scotia. Triangulation of results across the studies contributed to developing a comprehensive and rigorous description of the 3 dimensions of interest.

Thesis (Ph. D.)--University of North Texas, Aug.,, 2009. / Title from title page display. Includes bibliographical references.