BACKGROUND: In March of 2020, the novel coronavirus 2019 (COVID-19) pandemic required healthcare systems to be rapidly responsive to adapt hospital guidelines for the most up-to-date care and safety protocols as knowledge of the disease rapidly evolved. Rates of COVID-19 infections continue to fluctuate, and non-COVID-19 patients have now returned to the emergency department for care. This increase in patient volume leads to new challenges and threats to patient and clinician safety as suspected COVID-19 patients need to be quickly detected and isolated amongst other patients with non-COVID-19 related illnesses. In addition, emergency physicians face continued personal safety concerns and increased work burden on the front lines, heightening stress and anxiety. Burnout is a serious concern for emergency physicians due to the cumulative pressures of their daily practice, even under non-pandemic circumstances. Given the prolonged course of the pandemic, burnout may likely present as a longer-term outcome of these acute stressors. METHODS: A rapidly adaptive simulation-based approach was implemented to understand and improve physician preparedness while decreasing physician stress and anxiety. A randomized control trial was conducted to test the effectiveness of a simulation preparedness intervention on physician physiologic stress as measured by decreased heart rate variability on shift and anxiety as measured by the State-Trait Anxiety Inventory. OUTCOMES: Front-line EM physicians participated in a simulation-based educational intervention aimed to facilitate the adoption of protocols and treatment algorithms. Four virtual simulation scenarios highlighted the care pathways a practitioner might implement when managing a COVID-19 positive patient. A debriefing session followed each scenario to interactively analyze the learners' management decisions. The discussion focused on the most current hospital protocols so that any gaps in knowledge could be successfully addressed. The scenarios were iteratively updated, and the debriefing emphasis changed to deliver the newest clinical guidance and operational procedures as they evolved while continuing to highlight the aspects of care that remained challenging. Ongoing analysis of the physiological data is still being conducted. NEXT-STEPS: Mixed model analysis of physiologic and self-report measures of stress and anxiety will be used to determine if this virtual simulation intervention improves adherence to guidelines and protocols in the clinical setting and its impact on physicians while on shift. The next steps include further dissemination and objective feedback from institutions that may adopt this learning intervention.

The emergency department is a stressful environment. Emergency department registered nurses (ED RNs) are at an increased risk of development of negative and unhealthy psychological conditions due to their frequent exposure to stress and traumatic events. These conditions include post-traumatic stress disorder, compassion fatigue, and burnout syndrome, which are already known to be common in the emergency department registered nurse population. It is important to understand the factors that influence the development of these psychological conditions in order to provide better education to nurses regarding prevention of the development of these psychological conditions. This literature review aimed to identify articles that examined the factors associated with post-traumatic stress disorder, compassion fatigue, and burnout syndrome. Databases searched included but were not limited to CINAHL, MEDLINE, and PsycINFO. The determinants discussed in this paper include personality traits, social support, coping style, workplace violence, work environment, internal perceptions held by the nurse, and external perceptions held by the patient. Limited research exists regarding the factors influencing the development of compassion fatigue in the ED RN.

This project provides the first comprehensive investigation into the experiences of people with dementia (PWD), their carers, and the staff who provide care in emergency departments (ED) in the UK. This is a mixed methods study which used a national survey (N=403) followed by ED observation (32 hours) and qualitative interviews with health professionals (N=29), in an iterative and sequential design to present a holistic evaluation of the current experiences of the key parties- patients, carers, and ED staff involved in receiving and providing care. The theoretical perspective of the Human Factors Approach to patient safety underpins this work. The project included people with dementia and carers as collaborators and co-designers in both the development of the research tools and in shaping the project outputs. This research explores the barriers and facilitators to safe and effective care, concluding that here are a number of barriers (poor integration of communication systems, inappropriate physical environments, misalignment of staff training and workplace staffing models), which may affect the healthcare team’s ability to provide effective dementia care. These systemic challenges both give rise to and exacerbate poor organisational and safety cultures. However, despite these challenges, there are examples of safe and effective care (positive deviants) where uncommonly good outcomes for this patient population are achieved. Examining these examples offers valuable insight into potential adaptions, which could be used to improve existing care.

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<p><strong>Background:</strong> Syncope is estimated to account for 1% to 3% of emergency department (ED) annual visits in North America. Although most potential causes of syncope are benign and self-limited, others are associated with serious morbidity and substantial mortality. Recent efforts have focused on prospective identification of ED patients with syncope who are at high risk for early serious adverse outcomes in an attempt to hospitalize them at their first visit to the ED.</p> <p><strong>Objective: </strong>The purpose of this thesis is to describe the methodological issues related to the design of a study to determine whether the Revised Strategy of Syncope Diagnosis in the Emergency Room at the General Hospital Structured Care Pathway (RESASTER-SCP) is superior to usual care in identifying patients at low risk for serious adverse outcomes presenting to the ED who can be safely discharged home. <strong></strong></p> <p><strong>Design and Methods: </strong>A cluster randomized trial will be conducted with EDs (16 teaching and 46 non-teaching general hospitals) as the unit of randomization and patients presenting with syncope (TLOC) as the unit of analysis. Study participants will be followed at 1, 3, 5, and 12 months after the intervention (RESASTER-SCP vs. usual care) has been applied in the ED. Intention to treat analysis will be used. The analysis will be conducted at the individual level using proportions. Alpha level will be set at 0.05 with a power of 0.80 for the primary outcome.<strong></strong></p> <p><strong>Conclusion: </strong>This thesis describes some of the methodological issues concerning the design of a cluster randomized trial to determine whether or not RESASTER-SCP is superior to usual care in identifying patients presenting with syncope to the ED who can be safely discharged home.</p> / Master of Science (MSc)

<p><strong>BACKGROUND: </strong></p> <p>Emergency Department (ED) visit rates for patients with symptomatic, recent onset atrial fibrillation or atrial flutter (RAFF) are on the rise, which in turn has resulted in high hospital admission rates (38-45%). Optimal management strategies need to be developed for reducing hospital admission rates.</p> <p><strong>STUDY QUESTION:</strong></p> <p>The primary objective of this study is to evaluate the effectiveness of a clinical pathway for the management of low-risk RAFF patients in the ED. The hypothesis is that an evidence-based clinical pathway will help ED physicians better manage AF patients and reduce hospital admissions.</p> <p><strong>STUDY DESIGN:</strong></p> <p>A prospective, blinded, stratified, two-arm cluster-randomized trial will be conducted. The intervention is a clinical pathway for the management of RAFF.</p> <p><strong>PRIMARY AND SECONDARY OUTCOMES:</strong></p> <p>The primary outcome of this trial will be the proportion of low-risk, RAAF patients admitted to the hospital from the ED. Secondary outcomes will include a range of safety outcomes.</p> <p><strong>STATISTICAL CONSIDERATIONS:</strong></p> <p>An intention-to-treat analysis will be conducted at the individual level using proportions and means according to the variable in question with an alpha level of 0.05 and power of 0.80 for the primary outcome. The cRCT (assuming a 30% RRR) will be conducted over a two year time period. A total of 13 clusters and 3500 ED visits will be recruited to each intervention arm.</p> <p><strong>SUMMARY:</strong></p> <p>This thesis explores the methodological issues relevant to the design of a cRCT evaluating a clinical pathway in the management of acute onset, low risk AF patients presenting to the ED.</p> / Master of Science (MSc)

Through significant federal investment and incentives, Electronic Health Records have become ubiquitous in modern hospitals. Over the past decade, these computer support systems have provided healthcare operations with new safety nets, and efficiency increases, but also introduce new problems when they suddenly go offline. These downtime events are chaotic and dangerous for patients. With the safety systems clinicians have become accustomed to offline, patients are at risk from errors and delays. This work applies the Macroergonomic methodology to facilitate an exploratory study into the issues related to patient care during downtime events. This work uses data from existing sources within the hospital, such as the electronic health record itself. Data collection mechanisms included interviews, downtime paper reviews, and workplace observations. The triangulation of data collection mechanisms facilitated a thorough exploration of the issues of downtime. The Macroergonomic Analysis and Design (MEAD) methodology was used to guide the analysis of the data, and identify variances and shifts in responsibility due to downtime. The analysis of the data supports and informs developing potential intervention strategies to enable hospitals to better cope with downtime events. Within MEAD, the assembled data is used to inform the creation of a simulation model which was used to test the efficacy of the intervention strategies. The results of the simulation testing are used to determine the specific parameters of the intervention suggestions as they relate to the target hospitals. The primary contributions of this work are an exploratory study of electronic health record downtime and impacts to patient safety, and an adaptation of the Macroergonomic Analysis and Design methodology, employing multiple data collection methods and a high-fidelity simulation model. The methodology is intended to guide future research into the downtime issue, and the direct findings can inform the creation of better downtime contingency strategies for the target hospitals, and possibly to offer some generalizability for all hospitals. / Ph. D. / Hospitals experience periodic outages of their computerized work support systems from a variety of causes. These outages can range from partial communication and or access restrictions to total shutdown of all computer systems. Hospitals operating during a computerized outage or downtime are potentially unable to access computerized records, procedures and conduct patient care activities which are facilitated by computerized systems. Hospitals are in need of a means to cope with the complications of downtime and the loss of computerized support systems without risking patient care. This dissertation assesses downtime preparedness and planning through the application of Macroergonomics which has incorporated discrete event simulation. The results provide a further understanding of downtime risks and deficiencies in current planning approaches. The study enhances the application of Macroergonomics and demonstrates the value of discrete event simulation as a tool to aid in Macroergonomic evaluations. Based on the Macroergonomic Analysis and Design method, downtime improvement strategies are developed and tested, demonstrating their potential efficacy over baseline. Through this dissertation, the deficiencies in current contingency plans are examined and exposed and further the application of Macroergonomics in healthcare.

Bakgrund: Sepsis är ett av de vanligaste sjukdomstillstånden. Det är akut och uppstår på grund av att kroppens immunsystem reagerar på en infektion på ett extremt sätt. Det kräver en snabb handläggning på grund av den höga risken för skador och mortalitet. Specialistsjuksköterskor behöver på ett korrekt sätt kunna bedöma och prioritera dessa patienter för en säker handläggning. Syfte: Studiens syfte var att belysa prevention vid sepsis ur ett omvårdnadsperspektiv. Detta gjordes med begreppet “säker vård” som teoretisk utgångspunkt. Metod: Denna studie är utförd som en allmän litteraturstudie med en systematisk ansats, vilket bedömdes vara den mest lämpliga metoden för att få en klar översiktsbild av forskningsläget. De studier som inkluderades i översikten har ingen geografisk begränsning och inkluderade endast vuxna personer. De valda artiklarna kvalitetsgranskades och syntetiserades till kategorier. Resultat: I resultatet framkom tre kategorier med sju underkategorier. Den första kategorin var “Förutsättningar”. Den innefattade att det är av stor vikt att sjuksköterskor som vårdar patienter med sepsis har god kunskap om symtom och behandling. Dock framkom det att många sjuksköterskor inte hade adekvat kunskap om sepsis. Det framkom en vilja att lära sig mer hos personalen. Den andra kategorin var “Identifiering”. För att kunna säkerställa att patienter får hjälp i rätt tid så behövs tydliga rutiner och protokoll att luta sig mot. Finns det följsamhet till rutiner så är det gynnsamt. Den tredje kategorin var “Struktur”, vilken sammanfattningsvis visar att sjuksköterskans arbetsbelastning är för hög och även att adekvat bemanning minskar risken för patienter att dö av sepsis. Slutsats: Kunskapsnivån hos sjuksköterskor och patienter gällande sepsis är inte tillräcklig och mer utbildning på ämnet behövs. Skyndsamma åtgärder och struktur på arbetet är effektiva sätt att arbeta preventivt för att minska dödlighet i sepsis. Bemanningen på akutmottagningarna och avdelningarna behöver bli högre för att kunna arbeta säkert med den här patientgruppen. / Background: Sepsis is one of the most common medical conditions. It is acute and occurs because the body's immune system reacts to an infection in an extreme way. It requires prompt handling due to the high mortality rate for the affected. Specialist nurses need to be able to correctly assess and prioritize these patients for safe handling. Purpose: The purpose of the study was to investigate prevention of sepsis. This was done with the concept of "safe care" as a theoretical point of departure. Method: This study is carried out as a systematic review study, which was judged to be the most appropriate method to get a clear overview of the research question. The studies included in the review have no geographical limitation and included only adults. The selected articles were quality reviewed and synthesized into categories. Results: The results revealed three categories with seven subcategories. The first category was “Conditions”. It included that it is of great importance that nurses who care for patients with sepsis have good knowledge of symptoms and treatment. However, it emerged that many nurses did not have adequate knowledge of sepsis. The staff expressed a desire to learn more. The second category was “Identification”. In order to ensure that patients receive help at the right time, distinct routines and protocols are needed to rely on. If there is adherence to the working method, it is favourable. The third category was "Structure", which in summary shows that the nurse's workload is too high and also that adequate staffing reduces the risk of patients dying from sepsis. Summary: The knowledge level of nurses and patients regarding sepsis is not good enough and more training on the subject is needed. Prompt action and structure at work is an effective way to prevent and reduce mortality in sepsis. The staffing in the emergency departments and wards needs to be higher to work safely with this patient group.

O estudo tem por objetivo caracterizar a organização da rede de atenção de urgência do SUS no município de Ribeirão Preto, caracterizando a rede de pronto atendimento não hospitalar 24 horas, o processo de trabalho dentro da Central de Regulação de Urgência para avaliação da solicitação e as opções de encaminhamento dos pacientes, os hospitais conveniados ao SUS com sua disponibilidade de leitos de urgência, e a capacidade de resolução em termos de complexidade de recursos (humanos, diagnósticos e terapêuticos). Método: Estudo transversal, de caráter descritivo e retrospectivo. Os dados foram coletados nos bancos de dados da Secretaria Municipal de Saúde presentes nos Sistemas Hygia® e True® e exportados para planilhas do Microsoft Excel para consolidação. Resultados: O município está dividido em cinco distritos de saúde e cada distrito possui uma unidade não hospitalar de pronto atendimento de 14 urgência 24 horas: Central (Unidade Distrital de Saúde Central ou P.S. Central), Norte (Unidade Distrital de Saúde do Simioni), Oeste (Unidade Distrital de Saúde do Centro de Saúde Escola - Sumarezinho), Leste (Unidade de Pronto Atendimento - UPA - Leste) e Sul (Unidade Distrital de Saúde da Vila Virgínia). A rede hospitalar de referência do SUS de Ribeirão Preto é composta pelos hospitais: A, B, C, D, E, F, G e H. O número de regulações efetivas anual gira em torno de 41.000 regulações, a média de indeferimento de solicitações é de 2.468 e a média de casos regulados em vaga zero é de 5.741. Considerações finais: O aumento de atendimentos nos pronto atendimentos extrahospitalares, do número de solicitações, do número de solicitações indeferidas e do número de regulações realizadas em vaga zero, indicam a baixa resolutividade da rede pré-hospitalar fixa e a escassez de leitos hospitalares para pacientes agudos, o que prejudica o processo de assistência em todos os níveis de atenção do SUS. Um sistema único de informatização do processo regulatório possibilitará o desenvolvimento de indicadores de processo e resultados com subsídios para revisão de práticas, conceitos e estratégias / The purpose of this study is to characterize the organization of the SUS emergency network in the city of Ribeirão Preto, characterizing the network of 24-hour non-hospital care, the work process within the Emergency Regulation Center for assessment of the request and the patient referral options, hospitals agreed to the SUS with their availability of emergency beds, and the ability to solve in terms of resource complexity (human, diagnostic and therapeutic). Method: Cross-sectional study, with a descriptive and retrospective character. The data were collected in the databases of the Municipal Health Department present in Hygia® and True® Systems and exported to Microsoft Excel spreadsheets for consolidation. Results: The municipality is divided into five health districts and each district has a non-hospital 24-hour emergency care unit: Central (Central Health Unit or PS Central), North (Simioni District Health Unit), West (District Health Unit of the School Health Center - Sumarezinho), Eastern (Emergency Care Unit - UPA - Lest) and South (District Health Unit of Vila Virginia). The hospital network of reference of the SUS of Ribeirão Preto is made up of hospitals: A, B, C, D, E, F, G and H. The number of annual approved regulations revolves around 41,000 regulations and of these the average of rejection is of 2,468 and the average of cases regulated in vacancy zero is of 5,745. Final considerations: The increase in outpatient visits, the number of requests, the number of requests rejected and the number of regulations made in vacancy zero indicate the low resolution of the fixed prehospital network and the shortage of hospital beds for acute patients , which undermines the care process at all levels of SUS care. A unique system of computerization of the regulatory process will enable the development of process and results indicators with subsidies to review practices, concepts and strategies