Severe sepsis and septic shock comprise a significant number of emergency department (ED) admissions annually. With the advent of early goal directed therapies, early identification and intervention have become paramount in this population. Few studies, however, have examined the role of serum lactate as a predictor of mortality or endpoint to resuscitation among this population. We aimed to show that improved lactate clearance is associated with decreased 28-day in-hospital mortality. We retrospectively examined data from the Yale Sepsis Registry for patients with severe sepsis or septic shock who had lactate levels that were measured initially in the ED and subsequently when the patient arrived on the floor. This study received institutional review board approval. Lactate clearance was calculated as a percentage, and comparison between patients who cleared lactate and those who did not were made for mortality data as well as baseline characteristics and interventions required between the two groups. 207 patients (110 male) with mean age and standard deviation (SD) of 63.17 ± 17.9 years were examined. 136 patients (65.7%) were diagnosed with severe sepsis and 71 patients (34.3%) had septic shock. Of those with identified sources of infection, pneumonia was the most common (54 patients, 26.1%). There were 171 patients in the clearance group and 36 patients in the non-clearance group, all of whom had a mean time of 9 hours 8 minutes ± 4 hours 6 minutes between lactate measurements. 28-day mortality rates were 15.2% (26 patients) in the lactate clearance group and 36.1% (13 patients) in the non-clearance group (p<0.01). Vasopressor support within 72 hours of admission was initiated among 61.1% (22 patients) in the non-clearance group compared with 36.8% (63 patients) in the clearance group (p<0.01). Mechanical ventilation was required for 36.3% (62 patients) in the clearance group and 66.7% (24 patients) in the non-clearance group (p=0.001). Rates of severe sepsis, mean number of SIRS and organ dysfunction criteria, and initial creatinine were similar between the two groups; however, only 86.1% (31 patients) in the non-clearance group received intravenous fluids in the ED compared with 98.8% (169 patients) in the clearance group (p=0.002). 33.3% (12 patients) in the non-clearance group had chronic obstructive pulmonary disease (COPD) compared with 15.2% (26 patients) in the clearance group (p<0.05). The mean Mortality in Emergency Department Sepsis (MEDS) scores were 8.78 ± 3.96 for the clearance group and 10.4 ± 4.48 for the non-clearance group (95% CI, -3.1 to -.14, p<0.05). These results show significantly higher mortality rates among patients who do not clear their lactate in the ED. Additionally, these patients require vasopressor support and mechanical ventilation more often. Lactate clearance was significantly associated with receipt of fluids and may also reflect lower MEDS score. Our findings suggest lactate clearance could be used as an endpoint for ED resuscitation and in stratifying mortality risk among patients with severe sepsis or septic shock. Future studies might seek to prospectively validate these findings and incorporate multivariate analysis to determine factors affecting lactate clearance.

published_or_final_version / abstract / toc / Nursing Studies / Master / Master of Nursing in Advanced Practice

Syfte: Undersöka sjuksköterskor inom ambulanssjukvårdens erfarenheter och upplevelser av hot och våld i arbetslivet. Metod: Empirisk studie med kvalitativ ansats. Sex semi-strukturerade intervjuer genomfördes. Materialet analyserades med en innehållsanalys. Resultat:  Hot om våld och patienter med ett hotfullt beteende är en del av arbetet i ambulansen enligt informanterna. Med stöd av direktiv och riktlinjer från arbetsgivfaren prioriteras personalens säkerhet alltid först och vid varje patientkontakt görs en samlad analys av hotbilden. Ambulanssjuksköterskans bemötande är viktigt vid mötet av en hotfull patient. Studien ger en bild av att flera av informanterna beskriver att arbetet inom ambulanssjukvården kan upplevas otryggt eftersom man många gånger befinner sig i okända miljöer med begränsade resurser och vårdutrymmet i ambulansen upplevs som problematiskt då utrymmet är begränsat. På grund av en rädsla för att provocera patienten till ett våldsamt beteende görs endast de undersökningar som är mest nödvändiga. Undersökningar som gör ont eller som kan uppfattas provocerande av patienten eller andra närvarande utförs med försiktighet för att minska risken för att väcka agitation gentemot personalen. Kompletterande utbildning i hantering och bedömning av psykotiska och drogpåverkade ansågs relevant och efterfrågades. Några informanter påpekar även att larmcentralen bör bli bättre på att skicka med polis till misstänk hotfulla arbetsmiljöer. Slutsats: Prehospitalt arbete medför en stor risk att exponeras för hot och våld. Studien ger en bild av att ambulanssjuksköterskorna efterfrågar mer utbildning inom hantering och bemötande av hot och våld. / Objective: To study paramedics’ experiences and views of threats and violence in their daily work. Method: Empirical study with a qualitative approach. Six semi-structured interviews were performed. Results: Threats, violence and people with threatning behavior are a part of paramedics' daily work according to the participants in the study. With the support of directives and guidelines from the employer the safety of the staff is always to be prioritized first. At each patient contact, an overall threat assessment is performed. Ambulance staff attitude is important in the meeting of a threatening patient. The study provides a picture where several of the participants describe that working within the ambulance service may feel unsafe. This is due to the fact that they often find themselves in unfamiliar environments with limited resources. Fear of causing violent behaviour in the patient limits the staff to only adressing the most important vital parameters. Examinations that cause pain or might be percieved as provocative by the patient or others present on the scene are performed with caution to minimize the risk for aggression towards the staff. Also, the workspace in the ambulance is perceived as problematic as space is limited. Additional training in handling and assessment of psychotic and intoxicated patients is considered relevant and requested. Some patricipants also point out that the monitoring center should be better at sending the police to work environments that can be potentially threatening. Conclusion: Prehospital work involves a large risk of exposure to threats and violence. The study provides a picture of the ambulance personnel asking for more training in handling and addressing threats and violence.

The Service Profit Chain is a simple conceptual framework linking employee satisfaction and loyalty, customer satisfaction and loyalty, and financial performance. Although widely used by practitioners, the Service Profit Chain's series of hypothesized relationships between employee, customer, and financial outcomes has seldom been tested using data that span all components of the model. Using a modified version of the Service Profit Chain, this study explores service design in the ER. In essence, the Service Outcome Chain asserts that certain structural elements. through their impact on process, have the potential to positively influence outcomes in the ER. The Service Outcome Chain proposes that for quality service to be delivered to the end-user (patients). service providers (nurses. physicians) must receive the support of those who serve them (management, training, the design of jobs and the design of the physical setting). Organizations that create the proper set of structural conditions for employee work also provide a basis for the development of a positive service climate. A positive service climate influences service quality and the end results of patient satisfaction with service and patient empowerment. In this study, using data from frontline service providers and service recipients in the ER, principle chain relationships are explored. A mixed methods approach is applied to examine the relationships identified in the Service Outcome Chain. A survey of emergency nurses is conducted followed by case studies of two ERs where survey, interview and photographic methods arc applied. Insights into the relationship between the structural, process and outcome elements of service design are gained. In addition. findings about the how managerial practices and physical design significantly influence service climate and service quality are revealed. Some of the strongest results of this study point to the role of physical design and service climate in setting the stage for a quality service strategy in the ER. In sum, this research provides the first theoretical and empirical examination of the Service Profit Chain or a modified version of it. applied to public sector health care in general and ERs in particular. It also provides the first empirical examination of physical design, service climate and patient empowerment in the ER. The importance of these three elements has been highlighted by this research.

Emergency department (ED) registered nurses (RNs) can help empower patients toward greater wellbeing through health promotion and patient education (HPPE). The ED is often an individual's first and only access to the health care system, and is seen as an underused setting for HPPE. To investigate RNs' current attitudes and activites about educating patients in the ED, 223 Canadian ED RNs were surveyed using an adapted web-based questionnaire. The attitudes of ED RNs and their current HPPE activities were examined, as was the relationship between level of nursing education and these attitudes. Results showed that perceived importance is the major variable to explain HPPE. A relationship also exists between fewer barriers and feeling more comfortable providing HPPE to patients. More comfortable ED RNS are more likely to see the importance of HPPE. A relationship between perceived effectiveness of HPPE and the frequency of HPPE was found. In general, ED RNs believe that HPPE is important, but need to perceive that what they are providing is effective.

Diss. (sammanfattning) Stockholm : Karol inst., 2004. / Härtill 5 uppsatser.

Diss. (sammanfattning) Stockholm : Karol. inst., 2003. / Härtill 5 uppsatser.

Diss. Stockholm : Karolinska institutet, 2005.

Thesis (M.H.A.)--University of Michigan, 1966.

Thesis (M.H.A.)--University of Michigan, 1960.