Objectives: This study has been conducted to determine the levels of inappropriate use of the A&E for conditions that could be treated by GPs, the nature of the morbidity pattern of those conditions, the reasons why primary care services were not being utilized, and also examined the validity (i.e. sensitivity and specificity) of patient classifications undertaken by nurses at the time of admission within this local context. Study design and setting: A cross sectional study was conducted over a one year period and subjects were randomly selected from four A&E departments located across the four principle geographic regions of Hong Kong by stratified, two-stage sampling. Main outcome measure: The gold standard in differentiating true emergency cases and GP cases was based on a retrospective record review conducted independently by a panel of emergency physicians. A random sub-sample of those classified as GP cases was interviewed and compared to a matched (via morbidity status) sample of primary care patients who had attended a hospitals' GOPC in order to determine factors distinguishing these two patient groups. Multiple Logistic Regression was used to distinguish the difference between GP cases and matched GOPC primary care patients on significance and odds ratios of the variables. The morbidity pattern according to ICPC was tabulated and analysed for the 'true' A&E cases and non-urgent cases. Sensitivity, specificity and positive predictive values were computed for both non-weighted and weighted conditions. Results: The level of GP cases was found to be 57% with a significant higher proportion of patients in younger age group, and late evening. The morbidity pattern of those top 10 diagnoses of non-urgent cases was very similar to the Hong Kong general practice morbidity pattern for self limiting conditions. Closure of the clinic was the main reason for GP cases attending A&E. Other major reasons were deterioration of symptoms, GPs' inability to diagnose efficiently and patients' wish to continue medical treatment in the same hospital. Affordability was the most pronounced reason for utilising the GOPC, but did not apply to the A&E GP patients. The most accurate weighted nurses' triage classification had the average sensitivity of 75%, specificity of 65.7%, and positive predictive value of 54%. The most accurate weighted patients' self-triage classification yielded a sensitivity of 43.3%, specificity of 49.2%, and a positive predictive value of 38.6%. Conclusion: The reasons for high level of utilisation of A&E services are complex and reflect problems of delivery of GP services. There is an urgent need for the GPs to set up a network system to provide out of hours services, and also for a better interfacing between primary and secondary care, and between public and private sectors, so that patients can be referred back to GPs. The design and measures chosen for this study will help provide A&E policy makers and planners with relevant information for better addressing practical solutions. / Albert Lee. / Source: Dissertation Abstracts International, Volume: 73-01, Section: B, page: . / Thesis (M.D.)--Chinese University of Hong Kong, 2004. / Includes bibliographical references (leaves 137-151). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Electronic reproduction. [Ann Arbor, MI] : ProQuest Information and Learning, [201-] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Appendix 4 in Chinese.

This study examines the visibility of moral agency in the daily work and production of healthcare in emergency medicine at an urban emergency medical center in the United States. Through detailed ethnographic research, this study investigates how the work of paramedics, nurses and physicians within their professional practice spheres of emergency medicine constantly resolve challenges that make their moral agency visible. Several themes emerge from this study by examining and closely noting how these individuals interact and express less a principled bioethical script, but instead a personal one that is or is not explained by their professional role in treating patients. This study follows the daily conversations and interactions that embody the local moral worlds of emergency medicine in paramedics, nurses and physicians and how each of these professional groups work through and around medical and patient care issues to create care. As these individuals within their professional role address challenges in emergency care, it is their interactions and conversations that make visible the moral agency of the individual healthcare worker. By examining the domain of these work lives this study investigates the ongoing and new conflicts and resolutions for the healthcare workers and how they assert moral agency; the intersubjective local moral worlds of care; use of technology to mediate care; and the structure of medicine in emergency medical care.

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.

Emergency Medical Service (EMS) professionals are consistently exposed to a variety of traumatic events on the job, such as cases that involve the death or injury of a patient, being physically threatened, or encountering a mass casualty incident. Not surprisingly, research has found that such traumatic exposure has major implications, as it has been related to a plethora of negative strain outcomes such as posttraumatic stress (PTS) symptoms and burnout. However, at this point, research has not empirically examined the mechanisms by which these traumatic events lead to strain. Therefore, this study aims to further investigate these mechanisms by incorporating the role that emotion regulation (i.e., expressive suppression) plays in this process. Further, this study investigates various moderators in this process, including one individual difference factor (i.e., implicit theories about emotion expression) and two contextual factors (i.e., social support and organizational constraints). To test the links in the aforementioned process, a weekly diary study was conducted online with 200 current EMS professionals. Specifically, participants completed a baseline survey (Time 0) that measured trait-level variables and demographics. Then, participants completed 10 weekly diary studies that included measures of exposure to traumatic events, negative affective reactions, expressive suppression, and strain outcomes. Multilevel structural equation modeling was used to test the study hypotheses. Results of this study show that within person, traumatic event exposure was related to strain. Further, although traumatic event exposure was not consistently related to expressive suppression, the positive link between expressive suppression and strain was consistent. Additionally, organizational constraints were found to serve as a moderator in the relationship between expressive suppression and strain, such that higher organizational constraints exacerbate this relationship. Overall, these results provide a better understanding of the process that links traumatic event exposure to strain in the EMS profession. This research has implications for organizations, as it examines various factors that may be addressed in order to ensure that EMS professionals are better equipped to deal with these unfortunate exposures. Ultimately, the results of this study will hopefully prove helpful in devising interventions to enhance the wellbeing of EMS professionals in the wake of exposure to traumatic events.

The Helicopter Emergency Medical Service (HEMS) accident rate has driven operators from around the world to address the management of risks inherent to their operations. In-flight decision-making, pre-flight planning, failure to follow standard operating procedures, delayed remedial actions, and misinterpretation of environmental cues are all areas that need to be addressed for safe HEMS operations. HEMS operations are complex, being a joint exercise between the flight crew, paramedics and supporting agencies. Operations occur around-the-clock, in all-weather conditions, and often with no fore-warning. In a time critical operation, where precious minutes may cost lives, operators must decide which cases warrant a HEMS response and if so, whether the conditions are safe to conduct the mission. Intelligent systems are an emerging field offering benefits to a multitude of applications. This research forms a comprehensive investigation of the application of 'intelligent systems' to the pre-mission analysis of HEMS operations. The research has resulted in the development of a prototype decision support system capable of assisting in the pre-mission analysis of HEMS operations. The prototype system is capable of supporting flight coordinators and crew in the decision-making processes prior to HEMS operations and can potentially improve emergency medical services to the community.

Problem investigated: The activation and implementation of the Medical Emergency Team (MET) system. Procedures followed: The ability of the objective activation criteria to accurately identify patients at risk of three serious adverse events (cardiac arrest, unexpected death and unplanned intensive care admission) was assessed using a nested, matched case-control study. Sensitivity, specificity and Receiver Operating Characteristic curve (ROC) analyses were performed. The MET implementation process was studied using two convenience sample surveys of the nursing staff from the general wards of twelve intervention hospitals. These surveys measured the awareness and understanding of the MET system, level of attendance at MET education sessions, knowledge of the activation criteria, level of intention to call the MET and overall attitude to the MET system, and the hospital level of support for change, hospital capability and hospital culture. The association of these measures with the intention to call the MET and the level of MET utilisation was assessed using nonparametric correlation. Results obtained: The respiratory rate was missing in 20% of subjects. Using listwise deletion, the set of objective activation criteria investigated predicted an adverse event within 24 hours with a sensitivity of 55.4% (50.6-60.0%) and specificity of 93.7% (91.2-95.6%). An analysis approach that assumed the missing values would not have resulted in MET activation provided a sensitivity of 50.4% (45.7- 55.2%) and specificity of 93.3% (90.8-95.3%). Alternative models with modified cut-off values provided different results. The MET system was implemented with variable success during the MERIT study. Knowledge and understanding of the system, hospital readiness, and a positive attitude were all significantly positively associated with MET system utilisation, while defensive hospital cultures were negatively associated with the level of MET system utilisation. Major conclusions: The objective activation criteria studied have acceptable accuracy, but modification of the criteria may be considered. A satisfactory trade-off between the identification of patients at risk and workload requirements may be difficult to achieve. Measures of effectiveness of the implementation process may be associated with the level of MET system utilisation. Trials of the MET system should ensure good knowledge and understanding of the system, particularly amongst nursing staff.

Problem investigated: The activation and implementation of the Medical Emergency Team (MET) system. Procedures followed: The ability of the objective activation criteria to accurately identify patients at risk of three serious adverse events (cardiac arrest, unexpected death and unplanned intensive care admission) was assessed using a nested, matched case-control study. Sensitivity, specificity and Receiver Operating Characteristic curve (ROC) analyses were performed. The MET implementation process was studied using two convenience sample surveys of the nursing staff from the general wards of twelve intervention hospitals. These surveys measured the awareness and understanding of the MET system, level of attendance at MET education sessions, knowledge of the activation criteria, level of intention to call the MET and overall attitude to the MET system, and the hospital level of support for change, hospital capability and hospital culture. The association of these measures with the intention to call the MET and the level of MET utilisation was assessed using nonparametric correlation. Results obtained: The respiratory rate was missing in 20% of subjects. Using listwise deletion, the set of objective activation criteria investigated predicted an adverse event within 24 hours with a sensitivity of 55.4% (50.6-60.0%) and specificity of 93.7% (91.2-95.6%). An analysis approach that assumed the missing values would not have resulted in MET activation provided a sensitivity of 50.4% (45.7- 55.2%) and specificity of 93.3% (90.8-95.3%). Alternative models with modified cut-off values provided different results. The MET system was implemented with variable success during the MERIT study. Knowledge and understanding of the system, hospital readiness, and a positive attitude were all significantly positively associated with MET system utilisation, while defensive hospital cultures were negatively associated with the level of MET system utilisation. Major conclusions: The objective activation criteria studied have acceptable accuracy, but modification of the criteria may be considered. A satisfactory trade-off between the identification of patients at risk and workload requirements may be difficult to achieve. Measures of effectiveness of the implementation process may be associated with the level of MET system utilisation. Trials of the MET system should ensure good knowledge and understanding of the system, particularly amongst nursing staff.

Emergency departments (ED) provide access to care for large numbers of patients who have nonemergent medical needs. More than half of the patients presenting to the ED at Salem Hospital in Salem, Oregon, were found to be seeking care for nonemergent medical needs. In an effort to provide an alternative location for receiving this medical care, the hospital opened an Urgent Care Center (UCC) a few blocks from the ED. The purpose of this study was to determine who uses the ED, why, and what effect the UCC had on providing an alternative to the ED. My anthropological methodology uses both quantitative and qualitative techniques. Included in the study is a random retrospective chart review of 462 patients who utilized the ED and 183 patients who utilized the UCC. The collected data were analyzed and compared with information found in the literature review. Interviews with hospital staff and patients using the two facilities are integrated into the analysis. My own experience as a nurse allows me a certain insider's perspective which was useful in interpreting data, while doing observation, and during the interview process. Findings from my research show that the Urgent Care Clinic does provide an alternative source of health care to the ED for many people. This is particularly true for those whose usual source of care is unavailable and for those who are unable to find a primary care provider to accept them. The emergency department provides nonemergent care for large numbers of patients, some of whom have psycho-social problems which differ as compared to the general population. Some of these patients have moderate psychiatric dysfunction and/or addiction problems or homelessness as well as underlying medical problems, all of which are barriers to obtaining care in a regular office setting. In some cases, the emergency department provides the best option of available care. / Graduation date: 1999

This research study represents a personalized account of my experiences as a San Antonio Fire Department (SAFD) paramedic. In this study I bring the reader closer to the subculture of the Emergency Medical Services (EMS) through the research methodology of autoethnography. This qualitative method allows me to be researcher, subject, and narrator of the study. Autoethnography requires considerable attention to reflection, introspection, and self-analysis through the use of the narrative. Written in first person voice, I am positioned in the narrative in a manner that allows me to communicate directly with the audience. Through an insider’s perspective, I have traced the time I spent in EMS by reflecting, interpreting, and analyzing a collection of epochal events that significantly impacted my life both personally and professionally. There are five themes that I have identified as salient to the meaning-making process of the study: (a) death and dying, (b) faith and spirituality, (c) job burnout, (d) dealing and coping with job-related stress, and (e) alcohol abuse. The events that I have selected for this study may be read and interpreted as a prelude to what is a much broader narrative of my tenure in EMS and of other emergency responders’ experiences as well. The study explores how my life was impacted beyond the immediate experience and how the story continues to evolve to the present day. The study establishes a foundation for designing training programs to be used by public safety educators. Three theoretical elements of adult learning that help inform professional education strategies for emergency responders have been identified: (a) experiential, (b) narrative, and (c) transformative learning. The study also sensitizes the general public to the physical, social, and psychological demands that are placed on paramedics. It is important for the reader to know that these public servants are ordinary human beings doing extraordinary work in one of the most stressful and hazardous professions in the world.

Objectives: 1. To describe variations in major trauma between rural and urban residents of Ontario in terms of external causes, severities, prehospital care and clinical outcomes. 2. To determine whether prehospital intubation improves survival to hospital discharge among victims of major trauma. Methods: The study involved secondary analyses of data from the Ontario Prehospital Advanced Life Support Study (OPALS). OPALS is the largest study of prehospital emergency medical services conducted worldwide. 1. Rural-urban status of trauma patients was determined using modified Beale Codes. Differences in trauma characteristics and patient care were compared among four geographic groups (Large Metro, Medium Metro, Small Metro, Rural). 2. Patients who were intubated in the field were individually matched with non-intubated patients by patient age, injury severity score category, abbreviated head injury score category, and exact Glasgow coma scores. Cox regression was used to estimate the effect of prehospital intubation on patients' survival to hospital discharge, stratifying on patient matching. Results: 1. Patients in the large metro and rural groups had higher injury severity scores (medial 25, 24, respectively) than the other two groups (median=22). Paramedics generally spent more time in rural and large metro areas (median=37.4, 36.6 minutes respectively) than in medium and small metro (median=32.0, 30.7 minutes respectively) areas. Response times and transport times in rural groups were significantly longer than the other three groups, while scene times in the large metro group were significantly longer compared with the other geographic groups. There were no significant differences in survival rates by geographic group. 2. There were no significantly differences between the intubated and the non-intubated groups by age, sex, Glasgow coma scores, injury severity score, and systolic blood pressure category. Prehospital intubated patients exprienced a 3-fold risk of mortality after adjustment for potential confounders (HR2.9; 95% CI 1.4 to 5.8). Conclusions: 1. While response and transport times for major trauma were longer in rural areas, there were no significant differences in mortality in patients with different rural urban status. 2. Prehosptial intubation showed a negative association with survival among major trauma patients. Further randomized trials are required to invesitigate this clinical issue. / Thesis (Master, Community Health & Epidemiology) -- Queen's University, 2007-10-24 11:58:53.955