The purpose of this research is to determine an appropriate nurse staffing strategy for the Intermediate Care Unit (ICU) and the Critical Care Unit (CCU) of the Emergency Department at York Hospital in York, Pennsylvania. This strategy must adhere to certain administrative policies while keeping patient waiting times within allowable limits. Determining the proper number of resources in an emergency department is a difficult problem because while assistance must be provided without delay at any time, the available resources are restricted by the hospital budget. This research involves simulating the operations of the Emergency Department at York Hospital using the software package Arena 7.0 to evaluate how the system is impacted by various nurse staffing strategies. A microcomputer-based decision support system (DSS) for nurse scheduling that was first developed by Sitompul in 1991 has been implemented using Turbo Pascal 6.0 to generate twenty possible nurse staffing plans. The best alternative staffing plan has been evaluated by the simulation model to determine its effect on waiting times for patients. Specifically, patients are divided into five ESI levels, where ESI-1 patients are the most serious and ESI-5 patients are the least serious, and waiting times are provided for each patient type. While the DSS approach is useful in generating specific working schedules that are acceptable to the nurses' requirements, it is limited when developing an overall staffing plan. Specifically, the DSS requires a user-defined ratio of nurses working the various shifts, and this ratio must remain constant throughout each month even if patient arrival rates are known to be time dependent. As an alternative approach, OptQuest for Arena was employed to search for an overall nurse staffing plan. After providing Arena with 50 DSS-generated schedules that satisfy the nurses' requirements, OptQuest was used to determine the best schedule for each nurse to follow in order to minimize the average waiting time in the system for patients. Although the average waiting time obtained by the OptQuest staffing plan decreased from the current staffing plan for all patient types, a paired-t comparison determined using Arena's Output Analyzer indicated no statistical difference (at the 95% confidence level) between the DSS and OptQuest scenarios, in terms of the average waiting time for ESI-1 and ESI-2 patients. Further analysis indicated that a system bottleneck occurred in the triage area of the emergency department during evening hours. After adding one additional triage nurse in the evening shift, the OptQuest-generated staffing plan was re-evaluated. The results indicate that the suggested staffing plan reduced the average waiting time in the current staffing plan by 34.33%, 32.73%, 47.87%, 54.92%, and 52.41% for ESI-1, ESI-2, ESI-3, ESI-4, and ESI-5 patients, respectively. In addition, the average waiting time of ESI-1, ESI-2, ESI-3, ESI-4, and ESI-5 patients for the suggested staffing plan was 19.27%, 19.36%, 39.37%, 48.55%, and 46.64%, respectively, less than for the staffing plan determined when using the DSS approach alone. / Master of Science

Discounting is a behavioral analytic approach that focuses on the assumption that the value of a reward is increasingly discounted as the delay until or the odds against receiving the reward increase. Up to date, there are no studies that have looked at discounting with health care. The current study evaluated the relationship between increasing the cost of the emergency room and time willing to wait to seek medical attention for flu-like symptoms. A discounting task was given to 30 students at a Midwestern university. Results demonstrated that participants indicated that all participants demonstrated an Area Under Curve (AUC) value of less than .01, indicating that there were high levels of impulsivity. Correlational tests were conducted to assess response differences between gender, age and policy holder status. Overall, results demonstrated that as the cost of the emergency room increases, participants were willing to delay seeking medical attention. A hyperbolic function produced a strong fit for this study (R² = 0.95). Due to the population utilized for this study, most of the participants had available health insurance. A future extension of this study would be conducting this discounting task with individuals who do not have health insurance.

Emergency department (ED) crowding is a patient safety concern that has been increasing for more than a decade. Increased visits have resulted in ED crowding, longer wait times, ambulance diversions, and boarding of admitted patients (Hing & Bhuiya, 2012). Numerous factors affect ED crowding. Once various extraneous issues are resolved and a bed is available for a patient, it becomes the responsibility of nurses across unit boundaries to coordinate the patient transfer. This study applies Relational Coordination Theory (RCT) as a framework to provide nurses insight into the relational aspects of their work in the transfer of ED patients to inpatient beds. Relational coordination is a mutually reinforcing process of interaction between communication and relationships that is carried out for the purpose of task interaction. It is useful for coordinating work that is highly interdependent, uncertain, and time constrained (Gittell, 2002). Nurses work during ED transfers requires task interaction as they coordinate their efforts. This study, guided by RCT, will examine relational and communication dynamics among nurses within their own units and across unit boundaries as they interact during ED transfers. A cross-sectional, descriptive design will explore the seven dimensions of Relational Coordination (RC) during ED admissions and explain nurses relational and communication dimensions that may influence ED boarding times. The results of this study provide new information and a sound theoretical model on which to base future research.

Emergency department (ED) crowding is a serious problem in the United States. Crowding in the ED can result in delays that may negatively affect patient outcomes and increase the cost of care. The purpose of this project was to understand strategies that can help to improve patient flow in the ED. The plan-to-do-study act model for process improvement influenced this project. Secondary data were collected for a 2-month period to determine the impact of workflow processes (patient boarding time in ED, surge capacity and workflow processes including the impact of ancillary departments) on the movement of admitted patients from the ED to the inpatient units. Descriptive statistics were used to provide numerical summaries, frequencies, and percentages for the identified variables. The findings were consistent with an increased length of stay and longer ED boarding of patients due to the workflow process. Resulting recommendations included standardized calls for report on admitted patients within 30 minutes, timely discharge of patients, collaboration with attending physicians to facilitate evaluation of patients and orders, modification of staffing roles to ensure adequate staff, and identification of staff transporters to ensure timely transport of patients to their rooms. The findings helped to inform the development of a Bed Utilization Policy. The policy has been shared with the organization with the recommendation to implement and further evaluate to help manage bed flow. Development of utilization strategies that contribute to facilitating throughput will promote positive social change by providing nurses with the tools to help prepare for and respond to unexpected increases in patient volume. Improving efficiency with flow can help to improve patient care, timeliness, and safety.

The lack of nurses and the increasing turnover rate have been the main subjects when looking at the news about the health care sector. The constant lack of nurses can cause a lack of motivation and the nurses are leaving the workplaces, as the stress level rises. Nurses have also been discovered to have an impact on the patient satisfaction, which is why it is important to keep the nurses satisfied in their work. To understand what motivates the nurses and what could be done in order to make the situation better, more research is needed.  Non-financial motivation has been seen as a preferred way of motivating nurses in the hospital environment, which is why this study has a focus on it. Earlier studies have mainly focused on the nurse viewpoint of motivation and to further develop the understanding on the area, the viewpoint of managers is needed to be taken into consideration, to understand the issue more in-depth. To research the subject more, a study was conducted focusing on the emergency room at the University Hospital of Umeå and the nurses and managers working there.  The aim of this study is to understand how the views and preferences regarding non-financial motivation meet between the nurses and managers in the emergency room at the University Hospital of Umeå and which factors are the most preferred. Further, it is of interest to understand how this meeting of thoughts affects the everyday work and the motivation of the nurses. The following research questions was formed to answer the question:  How do nurses and their managers in the emergency room assess non-financial motivation factors?  The study has been conducted using qualitative methods and semi-structured face-to-face interviews. Additional data was gathered through e-mail interviews, as well as over telephone, and a reflective interviewee from another hospital was interviewed to gain more insight on the subject from another viewpoint.  The results from the study highlight the common importance for effective and emotionally intelligent leaders, who listen and have time for the subordinates. Further, work colleagues and the possibility for competence development were seen as commonly important factors to affect to the non-financial motivation of the nurses.  Practical implications from the study provide new data concerning the non-financial preferences and how the viewpoints meet and differ between nurses and managers who work in different roles in the hospital. Furthermore, this study could be of use to help to understand what could be done to better in order to motivate the nurses. Although, as the study is focusing on a specific department, it is important to acknowledge the impact and possible differences between the personnel chemistry and recent position changes.

Discharge instructions provided to patients discharged from the emergency department (ED) are often provided in a way that is neither clear nor concise. Patients are often discharged home without a clear understanding of their diagnosis, medications, reasons to return to the ED, follow-up instructions, or how to manage their care at home during their illness. Therefore, a guideline needed to be developed in order to help the ED staff provide clear and concise discharge instructions to patients discharged from the ED. The Ace Star Model of Knowledge Transformation was the foundation for the development of the evidence-based guideline. A formative group of 7 individuals was created to critique the initial draft of the guideline, and a final version of the guideline was then distributed to 10 medical professionals to aid in the approval and determination of the quality of the guideline. The data analysis from the formative group questionnaire, and the appraisal of guidelines for research and evaluation tool led to the recommendations for a guideline on the delivery of evidence-based discharge instructions. This project has implications for social change in practice by (a) increasing the awareness among medical professionals about the importance of their communication style on patient discharge and (b) allowing for more efficient communication to occur between them and their patients. The use of an evidence-based practice guideline for providing discharge instructions to patients discharged from the ED will allow improved quality of care to patients, efficient communication between the healthcare providers and patients, a positive impact for social change in practice, and a consistent and reliable method for patients to understand their discharge instructions in a way that is clear and concise.

名古屋大学博士学位論文 学位の種類:博士(医療技術学) (課程) 学位授与年月日:平成20年3月25日

Emergency Departments (ED) are highly dynamic environments comprising complex multi-dimensional patient-care processes. In recent decades, there has been increased pressure to improve ED services, while taking into account various aspects such as clinical quality, operational efficiency, and cost performance. Overcrowding has become a major barrier to receiving a proper and timely emergency care in many acute hospitals throughout the world. Patients often face long waiting times to be seen and treated. Those who require admission may even wait longer. The scope of this research is to focus on ED factors that lead to overcrowding and their management. Technology is being cited as one of the management tools, specifically the utilization of Radio Frequency Identification (RFID) for tracking patients as their journey progresses through an ED. Like any technology, RFID has potential and pitfalls. The author chose to use Failure Mode and Effect Analysis (FMEA) as a tool to explore the possible failures of RFID technology as it is utilized in one of the ED in Riyadh Military Hospital (RMH). This particular ED has been used as a case study to explore those failures and, with the use of FMEA, propose a set of recommendations to address those failures and improve the design and implementation of RFID. The experience of RMH-ED was explored through interviews and a survey in which 100 participants took part. The survey touched upon various aspects of this experience. This was due to the various roles of the surveyed staff who were involved with this technology. These roles ranged from front line clinical staff to administrative staff, management staff and technical support staff. Data analysis showed convincing evidence of the positive impact RFID had on managing ED overcrowding. However, and as expected, there are some pitfalls and failures that FMEA helped identifying and suggested potential solutions to them. RFID is a small link in the chain of other technological innovations and solutions. It is by no means capable of solving the problems associated with ED overcrowding by itself. Most of the search carried out by the author identified large variation in approaches to dealing with the issue of ED overcrowding. Those ranged from applying more human resources to altering the pathways of managing patients journey through healthcare system to applying more intermediate layers of management to ease the pressure of the Emergency departments. Other approaches included some aspects of technology such as development of early warning systems that have not been widely adopted and remained as isolated efforts.

Adolescent (14-17 year-olds) and young adult (18-20 year-olds) women account for a disproportionate 20% of the total number of unintended pregnancies that occur among women of all reproductive ages (14-55 year-olds) each year in the US. Nearly half (41%) of all unintended pregnancies result from the 18% of women who report inconsistent, incorrect, or no use of their contraceptive method. Evidence shows that a large proportion of these young women, especially those who are sexually active, come to the emergency department for their core sexual and reproductive health care needs. By obtaining a better understanding of the sexual and reproductive health needs and preferences of an urban population that is disproportionately low income and ethnically and racially diverse, our hope is to maximize adolescent and young adult accessibility to contraceptive services most feasible in the PED environment such as Nexplanon, in addition to the provision of comprehensive contraceptive counseling and education. OBJECTIVES: The first objective of this subgroup analysis is to determine the percentage of adolescent and young adult females presenting to an urban PED who are familiar with Nexplanon and to describe the demographic, sexual health, and contraceptive use characteristics of these young women. The second main objective of our study is to evaluate the sources of Nexplanon-related information reported by respondents familiar with Nexplanon. In addition to the main objectives, we also determine participant willingness to initiate or switch to Nexplanon® and receptivity to learning about contraceptive methods during a related or nonrelated visit to the PED. METHODS: This is a cross-sectional descriptive study using a paper-based anonymous questionnaire distributed to female patients, ages 16-21 years, presenting to a Boston urban pediatric emergency department (PED). This is a sub-group analysis of a larger study aimed at describing the contraceptive use history of young women who present to the PED. To identify if any statistically significant categorical variables existed between the two assigned groups, univariate analysis was performed using Chi-squared tests. Odds ratios with 95% confidence intervals (CIs) were obtained for the relationship between participants who have heard of Nexplanon and the three statistically significant variables: history of STDs, gravidity, and prior sexual intercourse with a male. Mean and Standard Deviation were used to describe the one continuous variable, age, followed by univariate analysis using independent t-test. Statistical significance was indicated using p-values for the categorical variables and odds ratio with 95% CI for the continuous variable—age. RESULTS: Of the 366 adolescent and young adult females included in our subgroup analysis, 230 (62.8%) indicated they were familiar with Nexplanon. We found that female participants familiar with Nexplanon were 1.3 times more likely to have had a prior STI, twice as likely to have had one or more previous pregnancies, and 3.5 times more likely to have previously engaged in sexual intercourse with a male compared to those female participants unfamiliar with Nexplanon. We also found that most (42.2%) female participants familiar with Nexplanon obtained their contraceptive information from their family and friends only, while about a third obtained their contraceptive information from medical professionals only. Among our total population of respondents, 6% (22/366) of our sub-group participants identified the contraceptive implant as their current method of contraception. Lastly, approximately 21% of female participants familiar with Nexplanon indicated current use of a long-acting reversible contraceptive method at the time of the survey. CONCLUSION: Overall, our study findings are supportive of and consistent with the provision and education of Nexplanon in the PED. This would be a crucial opportunity to provide comprehensive contraceptive counseling and convenient access to the most effective method of contraception among a population that disproportionately affected by unintended pregnancy. This can be made possible by enabling PED health care providers with the proper access to and training in Nexplanon. By adapting these patient-centered practices and techniques, the PED setting can contribute to the notable reduction in teen pregnancy seen in a variety of similar clinic-based interventions. The PED atmosphere has enormous potential to serve young women as an additional venue for contraception education and access.

ABSTRACTStudying patients' reduced autonomy in acute care is complicated. There are few studies describing the patient's perspective in acute intubations. This was a quantitative literature study, where the primary purpose was to examine if there were evidence based plans of action to improve patient safety with intubations at the emergency room. The main question was if an empathetic approach was included. The theoretical framework is based on Jean Watson and her philosophy of care and basic human needs, in this study concentrating on breathing. The method used was literature searches in the database PubMed/Medline and Cinahl, main search words were patient safety, intubation, checklists complications and nursing. Criteria for inclusion in this study: adult patients in need of acute intubation related to respiratory failure caused by various causes. Children under the age of 18 and intubations that were performed pre-hospital were excluded. 14 studies were included, four randomized intervention studies, five intervention studies without randomization and five observational studies. All studies were rated reasonably strong to very strong on the GRADE review template. The main group of results centered around patient safety that generated three subcategories in the form of checklists, preventive measures and structured work methods. No studies described guidelines that included empathetic approach.The literature identified 7 common factors for increasing patient security during intubation: teamwork, communication, simulation training, body position, pre-oxygenating, medication and experience/technique. Secondarily, results showed that checklists were good for patient security, when combined with a structured way of working.Conclusion: Guidelines were available concerning complications in emergency intubations and patient safety may increase if checklist is used. However, the literature study shows that the checklists lacked an empathetic approach in emergency situations with acute intubation. The literature study may be important as a basis for further research but another study design is proposed / SAMMANFATTNING Studera patienters nedsatta autonomi vid akuta omhändertaganden är komplicerat. Det finns få studier som beskriver patientens perspektiv vid akuta intubationer. Forskningsdesignen var en kvantitativ litteraturstudie, där det primära syftet var att undersöka om det fanns evidensbaserade riktlinjer för att förbättra patientsäkerheten vid akuta intubationer på akutrummet. Den viktigaste frågeställningen var om empatiskt förhållningssätt fanns inkluderat i riktlinjer. Det teoretiska ramverket knöts till Jean Watson och hennes filosofi kring omvårdnad och fundamentala mänskliga behov, i detta arbete ligger tyngdpunkten på andningen. Metoden var litteratursökning i databaserna PubMed/Medline och Cinahl, huvudsökorden var patient safety, intubation, checklist, complications och nursing. Inklusionkriterier var vuxna patienter i behov av akut intubation relaterat till respiratorisk svikt av olika orsaker. Barn under 18 år och prehospitala intubationer exkluderades. Totalt inkluderades 14 studier, varav fyra randomiserade interventionsstudier, fem interventionsstudier utan randomisering samt fem observationsstudier. Samtliga studier bedömdes ha måttligt starkt till starkt vetenskapligt underlag enligt GRADE granskningsmall. Resultatet visade en huvudgrupp med patientsäkerhet som genererade tre undergrupper i form av checklista, förebyggande metoder och strukturerat arbetsätt. Inga studier beskrev riktlinjer som inkluderade empatiskt förhållningssätt. I litteraturstudien identifierades sju gemensamma faktorer för att öka patientsäkerheten vid akuta intubationer; teamwork, kommunikation, simuleringsövningar, kroppsposition, preoxygenerering, läkemedel och erfarenhet/teknik. Sekundärt visade resultatet att checklistor var bra för patientsäkerheten, men att dessa bör kombineras med ett strukturerat arbetsätt. Slutsats: Riktlinjer finns gällande komplikationer vid akuta intuberingar och patientsäkerheten verkar kunna öka om checklista används. Litteraturstudien visar dock att checklistorna saknade ett empatiskt förhållningssätt i vårdsituationer med akut intubering. Litteraturstudien kan få betydelse som grund för vidare forskning men en annan studiedesign föreslås.