BACKGROUND: Patients visit the emergency department (ED) for life-threatening conditions, such as broken bones or chest pain, and non-life threatening conditions such as medication refills and pain management. Patients may make ED visits for non-life threatening conditions because they lack access to primary care. Research has shown that patients who are low-income, have chronic conditions, such as pain, and have depression are among those most likely to use the ED at a high rate. One of the most common reasons for visiting the ED is for pain relief, and therefore an intervention on patient self-management might prevent ED visits. The Program for Integrative Medicine and Health Care Disparities at Boston Medical Center (BMC) developed the Integrative Medicine Group Visit (IMGV) model to address chronic pain and depression among low-income patients, with the goal to improve patient’s adherence to self-management of pain and depression. The IMGV model consists of three non-pharmacologic components: evidence-based complementary medicine, mindfulness-based stress reduction, and group medical visits – all of which have been used to manage pain and depression. In a pre-post study of IMGV conducted in 2014, IMGV was associated with a significant decrease in ED utilization. Currently, the Program is conducting a randomized clinical trial (RCT) to compare a number of outcomes between the IMGV model and standard of care. The aim of this study was to determine if IMGV affects ED utilization in adult patients diagnosed with chronic pain and depression from an urban safety-net hospital population. METHODS: We conducted a secondary database analysis of participants enrolled in the IMGV RCT. The RCT is a two-armed study, and the medical chart review is part of the RCT. The study had patients who sought primary care at BMC and two affiliated outpatient urban community clinics. Only emergency visits made at BMC’s Emergency Department were included in our analysis. The inclusion criteria included reporting a pain level score > 4 on a 0-10 scale and having a score > 5 on the Patient Health Questionnaire-9. The intervention consisted of 10 IMGV sessions over 21 weeks. The control was standard treatment of care. Data extraction was completed in two ways: (1) the BMC Clinical Data Warehouse was extracted from Epic and (2) hand review took place by research assistant. The primary outcomes included ED encounters at two different time points: (1) 90 days before Session 1 and (2) Session 1 to Session 9. The extracted information also included information about patients’ chief complaints and discharge diagnoses. A visit was categorized as being a preventable emergency visit (PEV) or a non-preventable emergency visit (NEPV). Descriptive statistics and two-sample T-tests were used to analyze outcomes. RESULTS: At baseline, 22 of the 31 participants made at least one ED visit in the 90 days before Session 1. At 9-weeks, 14 of the 26 participants made at least ED visit. From baseline to 9-weeks, the number of participants who had at least one ED visit decreased for the intervention group (13 to 4), but increased for the control group (9 to 10). From baseline to 9-weeks, the number of visits decreased among intervention participants (16 to 5) but increased among control participants (11 to 12). The two-sample T-test, which compared the ED utilization among the intervention and control, resulted in the mean values of -0.7333 and 0.0625, respectively. This result indicated that intervention participants had overall lower ED visit use from baseline to 9-weeks. Emergency visits were also analyzed by whether they were PEV or NPEV. Of the 27 ED visits at baseline, 21 were classified as being a PEV, and 6 were classified as being a NPEV. Of the 17 ED visits at 9-weeks, the number of visits decreased for both PEVs (21 to 13) and NPEV (6 to 4). CONCLUSION: We wanted to determine if the IMGV reduces ED utilization in patients with chronic pain and depression. Our results suggest that the IMGV model may be associated with reduced overall ED utilization and reduced preventable ED visits. However, one limitation is that we have a very small sample size. This finding needs to be produced in an adequately powered clinical trial. Further research might explore the mechanisms for how the IMGV model can lead to lower ED utilization among patients with chronic pain and depression.

Der stetig wachsende Tourismus in den alpinen Regionen führt zu steigenden Einsatzzahlen der Berg- und Luftrettung in Bayern. Aufgrund der zunehmenden Notfälle werden die Retter*innen der Berg- und Luftrettung vermehrt in schwieriges Gelände gerufen und müssen sich mit unterschiedlichen Wetter- und Geländebedingungen auseinandersetzen. Diese erschwerten Umgebungsbedingungen können einen negativen Einfluss auf den Erfolg einer kardiopulmonalen Reanimation (CPR) haben. Diese prospektive Beobachtungsstudie umfasste 300 Teilnehmer*innen, die als Teil der Berg- oder Luftrettung Kenntnisse in der CPR haben. Die Teilnehmer*innen nahmen ohne Wissen über den Inhalt der Studie an 3 CPR-Trainingseinheiten teil, die sich durch erschwerte Umgebungsbedingungen voneinander unterschieden. Station Riegel bot den Retter*innen eine normale Trainingsumgebung. Station Höhe war durch eine exponierte, felsige Umgebung in 12 Metern Höhe charakterisiert. Station Kälte ist durch felsiges Gelände und Kälte von minus 20° C gekennzeichnet. An diesen 3 Stationen wurden 450 Trainings-sequenzen mit einem CPR-Phantom (AmbuMan Advanced) und Videoaufzeichnungen untersucht. Dazu wurden verschiedene Parameter wie z.B. Thoraxdrucktiefe analysiert, die entscheidend für einen langfristigen Erfolg einer CPR sind. Im Vergleich zur Station Riegel zeigten sich in den Stationen Höhe und Kälte signifikante Unterschiede von CPR-relevanten Parametern. Die eindrücklichsten Unterschiede zeigten sich im Bereich der Station 3 in Bezug auf die Ergonomie der Teilnehmer während der Thoraxdruckmassage, einhergehend mit verminderter Thoraxkompressionstiefe und zu geringen Beatmungsvolumina. Es zeigten sich keine Unterschiede zwischen den Gruppen in Bezug auf die Frequenz der Thoraxdruckmassage, dies ist auf die Verwendung eines im AED integrierten Metronoms zurückzuführen. Die vorliegende Studie zeigt, dass erschwerte Umweltfaktoren wie Höhe, Kälte und felsiger Untergrund einen negativen Einfluss auf die Qualität einer CPR haben. Die verminderte Thoraxkompressionstiefe und die unzureichende Ventilation können die neurologische Prognose der wiederbelebten Patienten negativ beeinflussen. Die Ergebnisse dieser Arbeit können Grundlage für eine weitere Optimierung der Trainingssituationen für die Berg- und Luftrettung in Bayern sein und unterstreichen die Bedeutung realitätsnaher Simulations-trainings.:I. Inhaltsverzeichnis II.Abbildungsverzeichnis III Tabellenverzeichnis IV.Abkürzungsverzeichnis 1 Einleitung 13 1.1 Herz-Kreislauf-Stillstand 13 1.1.1 Definition und Epidemiologie 13 1.1.2 Ursachen 14 1.2 Kardiopulmonale Reanimation (CPR) 15 1.2.1 Zielgrößen einer erfolgreichen CPR 17 2 Charakteristik der Berg- und Luftrettung in Bayern 18 2.1 Bergwacht Bayern 18 2.1.1 Aufgaben 19 2.1.2 Einsatzzahlen 19 2.2 Luftrettung in Bayern 20 2.2.1 Aufgaben 20 2.2.2 Einsatzzahlen 21 2.3 Ziel der Studie 21 3 Methodenteil 23 3.1 Aufbau der Studie 23 3.1.1 Studienteilnehmer 23 3.1.2 Organisatorisches 24 3.1.3 Trainingszentrum 24 3.2 Trainingssituationen 25 3.2.1 Station Riegel 25 3.2.2 Station Höhe 27 3.2.3 Station Kälte 28 3.3 Material und Technik 29 3.3.1 Reanimationsphantom 29 3.3.2 Notfallrucksack 31 3.3.3 Defibrillator 32 3.4 Auswertungsparameter Videosequenzen 32 3.4.1 Ergonomie 32 3.4.2 Herz-Lungen-Wiederbelebung unterbrochen 33 3.4.3 Position der Elektroden 33 3.4.4 Absaugung 33 3.4.5 O2-Anschluss 34 3.4.6 Filter 34 3.5 Auswertungsparameter Softwareaufzeichnung 34 3.5.1 Handpositionen 34 3.5.2 Fehlende Entlastung 35 3.5.3 Drucktiefe 36 3.5.4 Frequenz 36 3.5.5 Durchschnittliche Analysezeit 37 3.5.6 Zeit Schock – Kompression 37 3.5.7 Beatmung pro Zyklus 38 3.5.8 Durchschnittliche Zeit für zwei Beatmungen 39 3.5.9 Beatmungsvolumen 39 3.5.10 Durchschnittliche no-flow-time 40 4 Ergebnisdarstellung 42 4.1 Die Stationen Höhe und Kälte haben Einfluss auf die Ergonomie der Teilnehmer 42 4.2 Das Gelände zeigt keinen signifikanten Einfluss auf Unterbrechung der HLW 44 4.3 In der Riegel-Situation werden die Elektroden am häufigsten nicht korrekt positioniert 45 4.4 Es zeigen sich keine signifikanten Unterschieden zwischen den Stationen in Bezug auf die Absaugbereitschaft 47 4.5 In den Stationen Kälte und Höhe wird am häufigsten der O2-Anschluss nicht korrekt verwendet 48 4.6 Es zeigen sich keine Unterschieden zwischen den Stationen in Bezug auf die Verwendung des Filters 50 4.7 An der Station Kälte zeigen sich die häufigsten ungünstigen Handpositionen 51 4.8 Bei der Station Höhe zeigt sich eine fehlende Entlastung am häufigsten 53 4.9 Die Stationen Höhe und Kälte zeigen signifikanten Einfluss auf die Drucktiefe 55 4.10 Die Stationen zeigen keinen signifikanten Einfluss auf die Frequenz 57 4.11 An der Station Höhe zeigt sich ein signifikanter Einfluss auf die Analysezeit 58 4.12 Stationen Höhe und Kälte zeigen statistische Assoziation auf die Zeit Schock–Kompression 60 4.13 Stationen Höhe und Kälte zeigen signifikanten Einfluss auf die Beatmungen pro Zyklus 62 4.14 Station Kälte zeigt eine deutlich verlängerte Zeit für zwei Beatmungen 63 4.15 Ein zu geringes Beatmungsvolumen ist vor allem an der Station Kälte zu erkennen 65 4.16 Die längste durchschnittliche no-flow-time zeigt sich an der Station Kälte 66 4.17 Überkopf-CPR zeigt signifikanten Einfluss auf Drucktiefe 68 5 Diskussionsteil 70 6 Fazit 76 7 Zusammenfassung 77 V Literaturverzeichnis

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Strong earthquakes are frequent catastrophic disasters occurring worldwide and often lead to structural collapse of buildings. Urban Search and Rescue (USAR) is the specialised process of locating, extricating and providing immediate medical treatment to victims trapped in collapsed structures. This research project aimed to identify the key preparedness efforts necessary by an earthquake affected country to ensure best coordinated use of international USAR assistance.

Introduction : l'aptitude à prendre des décisions est cruciale en médecine d'urgence. Notre étude avait pour objectif de mieux comprendre comment les médecins urgentistes prennent des décisions. Méthode : nous avons réalisé une étude qualitative basée sur des entretiens semi-structurés avec des urgentistes. Les entretiens ciblaient la gestion d'une situation d'urgence courante. Ils reposaient sur la visualisation d'une vidéo de l'activité enregistrée en perspective subjective située. Résultats : plusieurs résultats sont originaux. Nous avons en particulier montré le rôle central joué par l'intuition dans la prise de décisions. Par ailleurs, nous avons mis en évidence la façon dont les médecins urgentistes génèrent et hiérarchisent les hypothèses diagnostiques. Conclusion : l'usage d'une approche méthodologique innovante nous a permis de mieux comprendre la façon dont les urgentistes prennent des décisions, avec plusieurs implications pour la formation. / Introduction: the ability to makes decisions is a crucial skill in emergency medicine. Our study aimed at revealing how and when emergency physicians make decisions during the patients' initial management. Methods : we carried out a qualitative research project based on semistructured interviews with emergency physicians. The interviews concerned management of an emergency situation during routine medical practice. They were associated with viewing the video recording of emergency situations filmed in an “own-point-of-view” perspective. Résults : many results are original. Specifically, we showed the major role played by intuition in the decision making process. Moreover, we revealed the way emergency physicians generate and evaluate diagnostic hypotheses. Conclusions : the use of an innovative research method allowed us to better understand the way emergency physicians make decisions in their everyday practice. Our results are associated with several implications for medical education.

Introdução: A Regulação Médica, que representa a aplicação de técnicas de logística ao contexto de emergência, é responsável pela disponibilização de recursos apropriados, nas condições apropriadas para pacientes apropriados. Um sistema para Regulação Médica de Urgências e Emergências foi desenvolvido em 2009 e foi implantado na forma de um projeto-piloto. Técnicas nas áreas de processamento de linguagem natural, recuperação de informação e aprendizado de máquina podem ser utilizadas para processar registros clínicos e auxiliar processos de tomada de decisão. Objetivos: No presente trabalho busca-se: (i) comparar diferentes metodologias para representação e extração de informação de documentos em texto livre, tais como solicitações de regulação; (ii) proporcionar suporte à decisão na definição de prioridade de casos, com processamento textual e semântico do resumo clínico dos casos; e (iii) analisar as contribuições dos dados clínicos e prioridade definida durante o processo de regulação para o desfecho do caso. Metodologia: Foram utilizados dados do projeto-piloto, assim como dados relativos ao desfecho do caso de pacientes regulados e admitidos na Unidade de Emergência do HCFMRP-USP. Os dados foram processados com o auxílio de tecnologias de Aprendizado de Máquina, Mineração de Textos e Recuperação de Informação para extrair informações organizadas em atributos a serem utilizados pra permitir suporte à decisão na prioridade do caso. Resultados: Os dados de pedidos de regulação apresentam uma grande quantidade de casos com valores de atributos muito parecidos (algumas vezes idênticos), contudo com classes (prioridades) diferentes, caracterizando uma base de dados com grande quantidade de ruídos, o que dificulta a aplicação de tecnologias como Aprendizado de Máquina. Resultados evidenciam o caráter subjetivo na definição de prioridades, que talvez seja influenciada por outros fatores que não estão presentes no texto do registro clínico do paciente. Resultados de suporte à decisão na definição de prioridade e desfecho do caso indicam que aplicar processamento semântico, mapeando termos para conceitos médicos do UMLS, reduz o problema da dimensionalidade quando comparado a abordagens menos robustas de mineração de textos. A abordagem apoiada por recuperação de informação, permite que sejam classificados apenas pedidos de regulação que sejam mais similares que um limiar (threshold) desejado em relação a algum caso do banco de dados. Desta maneira, esta abordagem pode ser utilizada para reduzir sobrecarga, permitindo que reguladores concentrem sua atenção em casos mais críticos e casos de maior particularidade (não similares a casos históricos). Conclusões: O presente trabalho proporcionou suporte à decisão na priorização de casos em regulações de urgência e emergência, com processamento textual e semântico do resumo clínico dos casos. Definiu-se como proposta para suporte à decisão na priorização de casos um processo composto por três etapas: (i) análise do risco de óbito; (ii) pré-priorização automática de casos de alta similaridade com casos históricos; e (iii) apoio à decisão com base em casos históricos (aprendizagem baseada em exemplos). / Introduction: The Medical Coordination, which is the application of logistics techniques to the emergency context, is responsible for providing appropriate resources, in appropriate conditions to appropriate patients. A system for medical coordination of emergency requests was developed in 2009 and was implemented as a pilot project, although some activities related to medical coordination decision making are extremely subjective. Techniques from the areas of natural language processing, information retrieval and machine learning can be used to process clinical records and assist decision-making processes. Objectives: The present study aims to: (i) compare different methodologies for representation and information extraction from free text documents, such as coordination requests; (ii) provide decision support to prioritization of requests, with textual and semantic processing of clinical summaries of the cases; and (iii) analyze the contributions of clinical data and priority defined during the coordination process to the final case outcome. Methodology: Data from the pilot project, as well as data on the case outcome of coordinated patients admitted to the HCFMRP-USP Emergency Unit we used. Data was processed with the aid of Machine Learning, Information Retrival and Text Mining techniques to extract information organized into attributes to be used to enable decision support on the priority of the case. Results: The coordination requests data contain a large number of cases with very similar attribute values (sometimes identical), but with different classes (priorities), characterizing a database with a large amount of noise, making it hard to apply technologies such as Machine Learning. Results denote the subjective aspect in the definition of priorities, which may be influenced by other factors that are not present in the patient\'s clinical record text. Decision support results in prioritization and case outcome indicate that applying semantic processing, mapping terms to UMLS medical concepts, reduces the dimensionality problem when compared to less robust text mining approaches. The approach supported by information retrieval allows to classify only coordination requests that are more similar than a defined threshold to a historical case. Thus, this approach can be used to reduce overhead, allowing coordinators to focus their attention on the most critical cases and cases of greater particularity (not similar to historical cases). Conclusions: This work provided decision support in prioritizing cases of urgency and emergency coordination requests, with textual and semantic processing of clinical summary cases. It was defined as a proposal for decision support in prioritization of requestes a process consisting of three steps: (i) analysis of the risk of death; (ii) automatic pre-prioritization of cases of high similarity with historical cases; and (iii) decision support based on historical cases (examples-based learning).

Objetivo: Analisar a Implantação do Componente Hospitalar da Rede de Urgências e Emergências- RUE na Região de Ribeirão Preto do Estado de São Paulo e propor uma matriz avaliativa. Método: Trata-se de um estudo avaliativo de análise de implantação do tipo I com abordagem quantitativa e qualitativa, realizado na Regional de Ribeirão Preto do Estado de São Paulo. Os 7 hospitais pesquisados foram aqueles contemplados no Plano de Ação Regional da RUE - PAR daquela região. Para coleta e análise de dados, foram elaboradas a matriz avaliativa, a matriz SWOT e realizadas entrevistas semi-estruturadas em eixos temáticos. Resultados: O eixo das portas de entrada atingiu nível satisfatório (entre 70,8 e 83,8%) e os eixos de enfermaria clínica de retaguarda e de leitos de terapia intensiva atingiram grau pleno de implantação (>90%). Destaca-se que a classificação de risco não foi implantada satisfatoriamente, e que alguns conceitos e atribuições precisam ser melhor apresentados e fomentados, tais como o Núcleo Interno de Regulação, o Núcleo de Acesso a Qualidade Hospitalar e o kanban. Dentre os fatores contextuais que mais ameaçam a implantação da RUE estão as dificuldades de regulação assistencial e a insuficiência de leitos de retaguarda e longa permanência. Considerações Finais: Os principais aspectos observados foram a implantação do cuidado multiprofissional e a comunicação inter-hospitalar por meio do Núcleo Interno de Regulação, os quais, ainda que com limitações, contribuíram na integração em rede e 12 na integralidade da assistência, fundamentais ao enfrentamento da fragmentação do cuidado, desafio maior das urgências e emergências no SUS. / Objective: To analyze the implantation of the Hospital Component of the Emergency and Emergency Network - RUE in the Ribeirão Preto Region of the State of São Paulo and propose an evaluative matrix . Method: This is an evaluative study of type I implantation with quantitative and qualitative approach, carried out in the Ribeirão Preto Region of the State of São Paulo. The 7 hospitals surveyed were those included in the RUE - PAIR Regional Action Plan for that region. For data collection and analysis, the evaluation matrix, the SWOT matrix, and semi-structured interviews were elaborated in thematic axes. Results: The axis of the entrance doors reached a satisfactory level (between 70.8 and 83.8%) and the axes of the clinical ward of the ward and of beds of intensive care reached a full degree of implantation (> 90%). It should be emphasized that the risk classification was not satisfactorily implemented, and that some concepts and attributions need to be better presented and encouraged, such as the Internal Regulation Nucleus - NIR, the Hospital Quality Access Center - NAQH and KANBAN. Among the contextual factors that most threaten the implementation of RUE are the difficulties of care regulation and the lack of back beds and long stay. Final Considerations: The main aspects observed were the implementation of multi-professional care and inter-hospital communication through the Internal Regulation Nucleus, which, although with limitations, contributed to the network integration and integral care, fragmentation of care, greater challenge of urgencies and emergencies in the SUS.

This exploratory mixed-methods study examines the experiences of Spanish-speaking patients seeking non-urgent care in an emergency department setting. Emphasis is placed on understanding variables that influence patient satisfaction among this particular special patient population. This study draws from the explanatory models of illness and perspectives of clinically applied anthropology in contributing to the limited body of scholarly work that utilizes ethnographic approaches in clinical spaces to investigate how patients experience seeking emergency care services. Health-related deservingness, social determinants of health, and health literacy are used as complementary frameworks in understanding the unique experiences of these patients. The combination of methodological approaches employed in this study included: participant observation (120+ hours), patient shadowing (40 hours, N=10), administration of a modified patient satisfaction survey (N=100), semi-structured interviews (N=25), and retrospective analysis of existing patient satisfaction data from the research site. Quantitative findings generally indicate high degrees of satisfaction among this particular patient population, with statistically significant differences when compared to English-speaking patients. Quantitative data also indicate how modality of communication with this patient population is important to consider in terms of patient comprehension and perceived levels of care/attention demonstrated by hospital staff. The qualitative findings from this project highlight the similarities in explanatory models of illness between this patient population and emergency medical providers. Qualitative data additionally elucidates many of the barriers Spanish-speaking patients face when seeking out non-urgent care such as: limitations in exercising individual autonomy when communicating with medical staff, self-blame for not being able to effectively articulate their symptoms and concerns, as well as lack of clarity in understanding follow-up care plans. The results from this study call for addressing issues pertaining to health literacy, specifically at the end of the clinical encounter when follow-up care and treatment plans are explained to patients.

A study to evaluate the level of hospital preparedness to respond to a bioterrorist attack such as smallpox or anthrax, in the western United States (Arizona, California, Idaho, Nevada, Oregon and Washington) was conducted from May to September 2000. A survey questionnaire was mailed to 300 randomly selected hospitals. A telephone survey followed. The data examined the population served, licensed bed capacity, median income of the population served, the geographic location, and the type of facility served. The findings from the 177 hospitals that answered the survey showed that only 28.8% of them had a specific plan in place in the event of a bioterrorist attack to their communities. More hospitals with large bed capacity serving large populations had plans to respond to the event of a bioterrorist attack than those hospitals with small bed capacity, usually serving small rural communities. Although the comparison of hospitals in each of the six western states showed no statistically significant difference between the number of hospitals with a plan to respond to a biological threat, hospitals in California showed the largest percentage of specific plans addressing biological events, followed by hospitals in the state of Washington. When the type of facility was considered, private hospitals more often developed a plan due to high-density population through their area than non-private hospitals, which indicates that bioterrorism plans may be developed when the funds are available. The most frequent answer given for not developing a plan was lack of adequate funding. Findings indicated a need for additional resources directed to hospitals, especially in rural areas. Because this study was conducted before the tragic terrorism events occurred in the United States in the fall of 2001, it may be considered a benchmark for future readiness evaluations of the response to the impact of those events in the Western states. / Graduation date: 2004

In this thesis, we study three emerging applications of OR/MS, namely, (i) disease spread modeling, intervention strategies, and food supply chain management during an influenza pandemic, (ii) the practical applications of production planning and scheduling in the commercial lithographic printing industry, and (iii) packing/placement problems in chip design in the semiconductor industry. In the first part of the thesis, we study an emergency response planning problem motivated by discussions with the American Red Cross, which has taken on a responsibility to feed people in case of an influenza pandemic. During an emergency such as an influenza pandemic or a bioterror attack, regular distribution channels of critical products and services including food and water may be disrupted, or some of the infected individuals may not be able to go to grocery stores. We analyze the geographical spread of the disease and develop solution approaches for designing the food distribution supply chain network in case of an influenza pandemic. In addition, we investigate the effect of voluntary quarantine on the disease spread and food distribution supply chain network. Finally, we analyze the effect of influenza pandemic on the workforce level. In the second part, we study a real life scheduling/packing problem motivated by the practices in the commercial lithographic printing industry which make up the largest segment of the printing industry. We analyze the problem structure and develop efficient algorithms to form cost effective production schedules. In addition, we propose a new integer programming formulation, strengthen it by adding cuts and propose several preprocessing steps to solve the problem optimally. In the last part of the thesis, motivated by the chip design problem in the semiconductor industry, we study a rectangle packing/placement problem. We discuss the hardness of the problem, explore the structural properties, and discuss a special case which is polynomially solvable. Then, we develop an integer programming formulation and propose efficient algorithms to find a ``good' placement.