Class of 2013 Abstract / Specific Aims: The purpose of this study was to assess the clinical and economic predictors associated with rural emergency department visits in stroke patients. Methods: The current research was a retrospective, observational, cohort study. Multivariate regression was used to assess data from the Agency for Healthcare Research and Quality (AHRQ) 2009 Nationwide Emergency Department Sample (NEDS). Inclusion criteria were at least 18 years of age and rural ED admission with principle diagnoses of stroke. Main Results: Significant results for risks included: Intubation for increased mortality (OR = 17.432, p = 0.001), increased length of stay (IRR = 1.643, p = 0.018) and increased charges (exp β = 2.289, p = < 0.001); myocardial infarction for increased mortality (OR = 1.969, p = 0.006), decreased charges (exp β = 0.862, p = 0.013) and decreased length of stay (IRR = 0.853, p = 0.001); moderate to severe liver disease for increased mortality (OR = 62.691, p = 0.001) and reduced length of stay (IRR = 0.517, p = 0.025); congestive heart failure for increased mortality (OR 1.978, p = 0.003) and increased charges (exp β = 1.118, p = 0.039); non-specific cancer (OR = 2.447, p = 0.017) and metastatic cancer (OR = 4.799, p = 0.016) for mortality; hemiplegia/paraplegia for increased charges (exp β = 1.173, p = < 0.001). Conclusion: The current study found a better understanding of national estimates of burden of illness to further define clinical decision rules for stroke in rural emergency departments.

No description available.

Patient satisfaction is a key outcome measure being examined by researchers exploring the relationships between patient outcomes and hospital structure and care processes. Only a few non-generalizable studies, however, have explored the relationship of nurse staffing and patient satisfaction with nursing care in emergency departments of hospitals. This dissertation aims to address that gap. Using more than 182,000 patient satisfaction surveys collected over a five-year period from 153 emergency departments (EDs) in 107 hospitals throughout Ontario, this study explores the relationship between nurse staffing and patient perceptions of nursing care in a range of Canadian ED settings, including urban and rural, community and academic, and small and large healthcare institutions with varying sizes and case mix. Using an established conceptual framework for investigating the relationship between nurse staffing and patient outcomes, nineteen nurse staffing variables were initially investigated. Ultimately, however, only five staffing variables were used in the multi-level regression analyzes. These five variables included registered nurse (RN) proportion, RN agency proportion, percent full-time nurse worked hours, RN worked hours per patient length of stay and registered practical nurse (RPN) worked hours per length of stay. Emergency department case mix index, patient age and gender, hospital peer group, size, wait times, cleanliness of the emergency department, physician courtesy, and year of measurement were controlled to account for their effect on the relationship between nursing staffing and patient satisfaction in the ED. The study revealed a subset of six patient satisfaction variables representing the overall variation in patient satisfaction with nursing care in the ED. Although RN proportion and RPN worked hours per length of stay were found to have a statistical association with patient satisfaction in the ED, the association was weak and not administratively actionable. Interpersonal and environmental factors such as physician and nurse courtesy, ED cleanliness and timeliness, however, were areas which hospital administrators should consider since they were highly associated with patient satisfaction in EDs.

Patient satisfaction is a key outcome measure being examined by researchers exploring the relationships between patient outcomes and hospital structure and care processes. Only a few non-generalizable studies, however, have explored the relationship of nurse staffing and patient satisfaction with nursing care in emergency departments of hospitals. This dissertation aims to address that gap. Using more than 182,000 patient satisfaction surveys collected over a five-year period from 153 emergency departments (EDs) in 107 hospitals throughout Ontario, this study explores the relationship between nurse staffing and patient perceptions of nursing care in a range of Canadian ED settings, including urban and rural, community and academic, and small and large healthcare institutions with varying sizes and case mix. Using an established conceptual framework for investigating the relationship between nurse staffing and patient outcomes, nineteen nurse staffing variables were initially investigated. Ultimately, however, only five staffing variables were used in the multi-level regression analyzes. These five variables included registered nurse (RN) proportion, RN agency proportion, percent full-time nurse worked hours, RN worked hours per patient length of stay and registered practical nurse (RPN) worked hours per length of stay. Emergency department case mix index, patient age and gender, hospital peer group, size, wait times, cleanliness of the emergency department, physician courtesy, and year of measurement were controlled to account for their effect on the relationship between nursing staffing and patient satisfaction in the ED. The study revealed a subset of six patient satisfaction variables representing the overall variation in patient satisfaction with nursing care in the ED. Although RN proportion and RPN worked hours per length of stay were found to have a statistical association with patient satisfaction in the ED, the association was weak and not administratively actionable. Interpersonal and environmental factors such as physician and nurse courtesy, ED cleanliness and timeliness, however, were areas which hospital administrators should consider since they were highly associated with patient satisfaction in EDs.

This research examined the impact of ED process complexity on hospital quality outcomes. Nine emergency department nurse managers from hospitals in Mississippi, Alabama, and Louisiana were interviewed regarding processes of registration, laboratory testing, medication administration, radiology, and discharge. Interview data was coded according to variables in proposed equations for patientocused, providerocused, and overall process complexity. Hospital quality was measured using existing process of care, outcome of care, and patient satisfaction standards. Results showed a strong negative correlation between process complexity and overall quality, suggesting that hospitals with lower process complexity experience higher quality outcomes. Regression analysis showed that the average number of patient steps in a process and the overall complexity the registration process were significant predictors of overall quality. Methods of reducing patient steps and registration process complexity are discussed.

Introduction: Caring for dying patients is part of working in a rural emergency department. Rural emergency nurses are prepared to provide life-saving treatments but find there are barriers to providing end-of-life (EOL) care. This study was completed to discover what the size, frequency, and magnitude of obstacles were in providing EOL care in rural emergency departments as perceived by rural emergency nurses. Methods: A 58-item questionnaire was sent to 52 rural hospitals in Idaho, Wyoming, Utah, Nevada, and Alaska. Respondents were asked to rate items on size and frequency of perceived barriers to providing EOL care in rural emergency departments. Results were compared with results from two previous emergency nurses' studies to determine if rural nurses had different barriers to providing EOL care. Results: The top three perceived obstacles by rural emergency nurses were: 1) family and friends who continually call the nurse wanting an update on the patient's condition rather than calling the designated family member; 2) knowing the patient or family members personally, and 3) the poor design of emergency departments which do not allow for privacy of dying patients or grieving family members. The results of this study differed from the other two previous studies of emergency nurses. Discussion: Nurses in rural emergency settings often work in an environment without many support personnel. Answering numerous phone calls removes the nurse from the bedside of the dying patient and is seen as a large and frequent obstacle. Personally knowing either the patient or members of the family is a common obstacle to providing EOL care in rural communities. Rural nurses often describe their patients as family members or friends. Caring for a dying friend or family member can be intensely rewarding, but can all so be very distressing. Conclusion: Rural emergency nurses live and work on the frontier. Little EOL research has been conducted using the perceptions of rural emergency nurses possibly because of the difficulty in accurately accessing this special population of nurses. Rural emergency nurses report experiencing both similar and different obstacles as compared to their counterparts working in predominately urban emergency departments. By understanding the obstacles faced by emergency nurses in the rural setting, changes can be implemented to help decrease the largest barriers to EOL care which will improve care of the dying patient in rural emergency departments. Further research is also required in the area of rural emergency nursing and in EOL care for rural patients.

When an emergency department (ED) decides that it is not going to be able to serve any more newly arriving patients, it declares "diversion". When an ED is on diversion, it suspends arrivals that can be controlled by forcing some or all of the incoming emergency medical system (EMS) transport units to search for alternate treatment facilities for their patients. This search causes both patients and EMS crew to loose valuable time. Contrary to the general belief that suggests diversions are not very common, the results of the American Hospital Association survey present an example where one third of the studied hospitals were on diversion more than 20% of the three-day study period. Past research indicates that the lack of critical care beds in the hospital is the primary contributor to ambulance diversion. When patients need to be transferred from the ED to the hospital with no available beds in the hospital, they continue occupying their beds (i.e. the patient is boarding). While they are boarding in the ED, the associated staff is idle, and their bed cannot be used to treat other patients. Boarders in the ED lead to gridlock, which is defined as the situation when no new patient can be accepted to the ED until a hospital bed becomes available. In this research, we developed a predictive model to provide probabilities of entering gridlock within a time horizon, given the current state of the system. These real-time predictions are provided for a relatively short time horizon, and in order to be useful, they need to be used in conjunction with effective preventive measures that can be applied quickly. The predictive model is based on a queueing theoretic approach and encapsulated in a user-friendly Visual Basic program in order to calculate and provide gridlock probabilities. Two systems, one with low (24% - System 1), and one with high (81% - System 2) gridlock probability were simulated in conjunction with our predictive model and preventive measures. When a gridlock was found imminent, the number of ED beds was temporarily increased, attempting to prevent gridlock. With only 3 additional beds, the probability of gridlock decreased to 6% in System 1 and 58% in System 2. With 5 additional beds, gridlocks in System 1 were almost eliminated while System 2 entered gridlock only 34% of the time. Our results indicate that by temporarily increasing the number of ED beds in the event of an imminent gridlock, the proportion of time that system enters gridlock can be significantly reduced. / Master of Science

The uptake of evidence in practice remains a challenge for healthcare professionals including nurses and providers. Increased use of evidence-based practices in healthcare settings may improve patient conditions such as pain and decrease the cost of healthcare. A wealth of literature can be found describing barriers and facilitators of evidence-based practice (EBP), and a movement in research has begun to focus on what influences the use of EBP. This study explored the relationships of context including the elements of individual, unit, and hospital and the use of evidence-based nonpharmacological pediatric pain management practices (EBNPP) using an existing data set of nurses and providers caring for children in the Emergency Department. Initial analysis found several significant correlations with individual, unit, and hospital context elements and EBNPP. A significant correlation was not found between evaluation and EBNPP and Magnet Status and EBNPP for nurse or providers. Nurse regression analyses showed knowledge and continuing education were significant predictors of EBNPP. Overall context was a significant predictor of EBNPP for both the nurse and provider models. A pooled regression analysis with Registered Nurses and Providers found nurses had a significant increased use of EBNPP when compared to providers. Regression analyses found that while overall context is a significant predictor of EBNPP, no single element was significant when all three were added to the model. The effect of context on EBNPP did not differ by profession in this sample. Results of this study indicate that while context is important in the uptake of EBNPP, one area does not have more influence than another. The variables explored in this study account for 13% of the variance in EBNPP. Future research should focus on the overall influence of context on EBP and consider other factors that may play a role in the uptake of EBP.

CHDS State/Local / This thesis addresses the role of the emergency department in planning for mass casualties during an emergency. The demand on hospital emergency departments has stretched the capacity for normal operations beyond their original design. Hospital surge capacity is not only complex, but affects every hospital emergency department in the country. Factors, such as hospital bed capacity, surge levels, staffing and the use of volunteers in time of emergency, all play a critical role in the ability and accessibility of the hospital to react during times of need. The recommendations provided are based on the analysis of county, state and federal plans along with case studies that provide a varied approach to emergency preparedness and the role of the hospital, focus on some of the facets of preparedness and the immediate need for emergency planning, training/exercising and communication in hospitals across America, and specifically, in hospitals in South Carolina.

Bakgrund : Våld på arbetsplatser och då särskilt inom sjukvården är ett växande problem. Akutmottagningar utgör en av de största riskavdelningarna för sjuksköterskor att drabbas av våld från patienter och deras anhöriga. En akutmottagning har öppet dygnet runt vilket resulterar i ett stort patientflöde och en ökad arbetsbelastning för sjuksköterskor. Syfte : Syftet med litteraturöversikten är att belysa våld på akutmottagningar med fokus på sjuksköterskans upplevelser och arbetssituation. Metod : Studien genomfördes som en litteraturöversikt. Resultatet baseras på 15 vetenskapliga artiklar med kvalitativ och kvantitativ ansats. Resultat : Att arbeta som sjuksköterska på en akutmottagning innebär en risk för att utsättas för verbalt och/eller fysiskt våld från såväl patienter som deras medföljande. Den grupp av sjuksköterskor som oftast drabbas av våld är yngre kvinnor med kort arbetslivserfarenhet inom akutsjukvård. Det verbala våldet dominerar jämfört med fysiskt våld. Våld skapar en mängd olika känslor hos sjuksköterskor, bland annat rädsla, oro, ångest, ilska och en form av acceptans. Känslorna kan ha en inverkan på sjuksköterskors förmåga att ge en optimal vård. De flesta som utsatts för våld under sitt arbetspass valde att inte rapportera det vidare uppåt i organisationen. Slutsats : Runt om i världen visar statistik på att en nyutexaminerad ung kvinnlig sjuksköterska som börjar arbeta på en akutmottagning har en hög risk att utsättas för våld från patienter jämfört med äldre med längre erfarenhet. Sjuksköterskors arbetssituation och hälsa påverkas negativt av våld. Det ger en ökad risk för sjukskrivning och vantrivsel på arbetet. Utsatta sjuksköterskor upplever att de inte kan ge optimal omvårdnad under ett våldsamt möte. Resultatet visar också på att många sjuksköterskor efterfrågar mer utbildning och tydligare rutiner kring hantering och rapportering av våld. / Background: Violence in the health care profession is a growing problem. Emergency departments are one of the more high risk areas for nurses to be subjected to violent acts from patients and their accompanied family. An emergency department is open around the clock which results in high patient flow and an increased work load for nurses. Aim : To illustrate violence in emergency departments with an emphasis on nurses’ experiences and work situation. Method : The study was conducted as a literature review. The results are based on 15 scientific articles with a qualitative and quantitative approach. Results: Working as a nurse at an emergency department means a risk of being subjected to violence from patients and their accompanied family or friends. Most prone to be subjected to violence are younger nurses with a short work experience in emergency care. Verbal abuse dominates the physical violence. Violence create different feelings among the nurses such as fear, anxiety, anger and a form of acceptance. These feelings may have an impact on nurses’ ability in providing optimal care. Most of the nurses subjected to violence during their work chose not to report the event to their supervisors. Conclusion : International statistics shows that a recent graduate young female nurse working at an emergency department has a high statistic risk of being subjected to violence from patients and their accompanied family or friends. Nurses’ work situation and health are negatively affected by violence. This may lead to an elevated risk of the need for sick leave and dissatisfaction at work. The results implicate the need of more education and clearer routines on how to manage and report violent incidents.