Knä- och höftplastik är bland de vanligaste kirurgiska ingreppen och har en stor positiv inverkan för den enskilda individens livskvalitet. Det har utarbetats flera vårdmodeller för patientkategorin som genomgår en knä- eller höftplastik, dels för att minska vårdkostnader men även för att förbättra vården. Det behövs emellertid mera kunskap om patientens upplevelse eftersom vården är i ständig utveckling. Studiens syfte var att beskriva patientens upplevelse av hemgång från en specialiserad elektiv enhet, den första postoperativa dagen efter knä- eller höftplastik, och första tiden efteråt. Telefonintervjuer utfördes med 12 patienter, och analyserades enligt kvalitativ innehållsanalys, med en induktiv ansats. Resultatet utmynnade i fem huvudkategorier med respektive underkategorier. Huvudkategorierna som framkom var; Den betydelsefulla hemmiljön, Information från sjukhuset, Oundvikligt hjälpbehov, Återhämtningens utmaningar och Hälsofrämjande kontakt. Informanterna delade en positiv upplevelse av hemgång den första postoperativa dagen och kunde hantera eventuella svårigheter på ett adekvat sätt, på egen hand eller med stöd av medskickad dokumentation, anhöriga eller kontakt med sjukhuset. Hemgång dagen efter knä- eller höftplastik upplevs som tryggt. / Knee and hip arthroplasty are among the most common surgeries available today and have a great impact on the quality of life of the individual. Several care models have been developed for patients having had knee or hip arthroplasty, not only to address the cost of healthcare, but also to improve the quality of the care itself. However, more knowledge about a patients experience following surgery is required as the care is continually progressing. The purpose of this study was to document the experience of a patient following a knee or hip arthroplasty. We aim to document their experiences returning home from a specialized elective unit, their first day post operation, as well as the initial period of recovery. Phone call interviews were carried out with 12 patients, and analyzed according to qualitative content analysis with inductive approach. The results were divided into five main categories, each with their own sub-categories. The main categories were; the importance of the home environment, information from the hospital, the necessity of help, challenges of recovery and health promotion contact. The participants reported a positive experience returning home after the first postoperative day and were able to handle potential issues in an adequate manner; on their own, with support from informative documentation, with help from relatives or through contact with the hospital. The experience of returning home the first day post operation, after a knee or hip arthroplasty is considered comfortable.

Seit Mitte der 1990er Jahre haben sich Fast-Track-Behandlungskonzepte in der Kardioanästhesie etabliert. Diese zielen darauf ab, unter Verwendung kurzwirksamer Anästhetika eine frühzeitige postoperative, tracheale Extubation der Patienten zu gewährleisten, und folgend die Dauer der postoperativen Behandlung auf der Intensivstation und im Krankenhaus sowie die Inzidenz an Komplikationen zu senken. Kernstück eines multimodalen, kardioanästhesiologischen Fast-Track-Konzeptes am Herzzentrum in Leipzig (HZL) ist eine postanästhesiologische Aufwacheinheit (PACU) mit 3 Patientenplätzen, in der Patienten postoperativ betreut werden, ohne dass eine Aufnahme auf die Intensivstation (ICU) erfolgen muss. Ziel dieser Arbeit ist, den Einfluss der PACU im Rahmen des Fast-Track-Konzeptes im Vergleich zur Behandlung auf der Intensivstation zu untersuchen. Hierzu führten wir eine prospektiv-randomisierte kontrollierte Studie mit insgesamt 200 elektiven, kardiochirurgischen Patienten durch. Resultat der Studie war eine signifikant kürzere Dauer bis zur Extubation in der PACU im Vergleich zur Kontrollgruppe, zudem war die Verweildauer in der PACU im Median signifikant kürzer als auf der ICU. Hinsichtlich der postoperativen Mortalität und Morbidität zeigten sich keine wesentlichen Unterschiede. Hieraus lässt sich schlussfolgern, dass eine postoperative Fast-Track-Behandlung in einer dedizierten PACU im Vergleich zur ICU zur früheren Extubation und Verlegung auf die weiterversorgenden Stationen führt, ohne dass die Sicherheit der Patienten beeinträchtigt wird.:Vorbemerkung Erklärung zum wissenschaftlichen Beitrag des Promovenden zur Publikation Bibliographische Beschreibung I. Einführung I. 1. Einführung und Grundlagen der Fast-Track-Rehabilitation I. 2. Entwicklung des Fast-Track in der Kardioanästhesie (FTCA) I. 3. Wesentliche Elemente der FTCA und deren Evidenz I. 4. Fast-Track-Behandlung am Herzzentrum Leipzig I. 5. Zielstellung der Arbeit II. Publikation III. Zusammenfassung III. 1. Hintergrund III. 2. Zielsetzung III. 3. Methode III. 4. Ergebnisse III. 5. Schlussfolgerung IV. Anlagen IV. 1. Literaturverzeichnis IV. 2. Verzeichnis der verwendeten Abkürzungen IV. 3. Eigenständigkeitserklärung

This dissertation presents an analysis of small-scale farmers’ experiences of and responses to the Fast Track Land Reform Programme in Zimbabwe. It is argued that this topic has been understudied, especially in the geographical areas of Mushandike and Mvurwi. The study employs both qualitative and quantitative research designs. Data collection techniques include questionnaires, participant observation, life histories, interviews and focus group discussions. Theories and debates on land reform and poverty alleviation that inform this study are discussed. It was evident from the field research that small-scale farmers experienced an improvement in their quality of life as was witnessed in improved levels of income, diets, types of housing and acquired assets. Land distribution according to gender is a particular concern. Very few women own land despite the fact that they till the land. The study concludes that land reform is essential for the improvement of the lives of the landless and the rural poor. Support systems are however necessary to achieve improved livelihoods. / Dissertation (MSoSci (Development Studies))--University of Pretoria, 2014. / Anthropology and Archaeology / MSc / Unrestricted

This thesis is about risk management in fast-track construction projects. The aim of the study is to identify the risks in the UAE construction industry, understand how they are dealt with, and propose more effective frameworks for risk management in fast-track construction. A mixed method approach was used to fulfil the objectives of the study. 65 questionnaires were distributed to professionals in the construction industry, including contractors, sub-contractors, project managers and private consultants. Their responses were analysed using statistical techniques, and the results taken for discussion to a focus group of eleven experienced construction managers and experts. Secondary data was also collected via literature reviews of print and website articles, and of books and documents from company, government and industry-specific databases. The findings show that risks in construction projects can be internal or external, and that in the UAE, owner- and design-related risks are seen as the most significant. Knowledge about risk management is present, but more needs to be done to eradicate the problems associated with poorly managed fast-track construction projects. Using the suggestion of the focus group, a framework for risk mitigation was developed based on the Alien Eyes’ risk and Qualitative Risk Management models. The study discusses the implications of risk management for practitioners and academicians in the construction industry. Poor risk management, which is usually the consequence of inadequate recognition of and/or responsiveness to risks and uncertainties, can have a devastating impact upon projects. It is hoped that practitioners applying the findings and suggestions in this study will see positive change, improved profitability and greater competitive advantage as a result.

Das kolorektale Karzinom zählt zu den häufigsten Malignomen der westlichen Welt. Bei Männern ist es der dritt-, bei Frauen der zweithäufigste zum Tode führende, bösartige Tumor. Aufgrund verbesserter Vorsorgeuntersuchungen werden die Tumore in immer früheren Stadien entdeckt. Dadurch können mehr Patienten unter kurativem Ansatz therapiert werden, was auch dazu führt, dass immer mehr Patienten mit der Erkrankung und den Auswirkungen der Therapie leben müssen. Nicht nur für das Wohlbefinden der Patienten, sondern auch unter wirtschaftswissenschaftlichen Gesichtspunkten ist es wichtig, Komplikationen zu vermeiden, den postoperativen Aufenthalt so kurz wie möglich zu gestalten und die Rekonvaleszenz zu beschleunigen. In den letzten Jahrzehnten ist es gelungen, Morbidität und Mortalität durch Maßnahmen wie strikte Einhaltung der Sterilität, verbesserte chirurgische Techniken, antibiotische Kurzzeitprophylaxe und präoperative Darmvorbereitung drastisch zu senken. Die Darmvorbereitung allerdings wird in letzter Zeit in zahlreichen Studien kontrovers diskutiert, nicht nur wegen der Nebenwirkungen, sondern auch, da einige Autoren in ihr eine Quelle für postoperative Komplikationen wie Wundheilungsstörungen, Infekte und Anastomoseninsuffizienzen sehen. Ziel der vorliegenden Arbeit war es, Nutzen und Risiken der präoperativen Darmvorbereitung kritisch zu bewerten. Zusätzlich wurden die aufgetretenen Komplikationen erfasst und deren Einfluss auf die Rekonvaleszenz betrachtet. Außerdem wurde ein besonderes Augenmerk auf die Lebensqualität und die Zufriedenheit der Patienten gelegt. Insgesamt wurden dafür die Daten von 100 Patienten erfasst, die sich zwischen April 2005 und Mai 2007 im Zentrum für Operative Medizin der Universität Würzburg einer elektiven onkologischen Darmresektion unterziehen mussten. Als Grundlage für die Datenerhebung dienten, neben mehrfachen persönlichen Gesprächen, die chirurgischen Krankenakten, Prämedikations- und Narkoseprotokolle sowie Operations- und Pflegeberichte, Pathologiebefunde, Arztbriefe und das Kliniknetzwerk der Universitätsklinik Würzburg (SAP). Außerdem wurden noch mehrere von den Patienten ausgefüllte Fragebögen erfasst und alle gesammelten Daten statistisch ausgewertet. Es wurden 67 Männer und 33 Frauen im Alter zwischen 40 und 86 Jahren operiert. Etwa die Hälfte der Patienten wurde vor dem Eingriff darmvorbereitet. Auffällig war, dass vor allem Patienten mit vielen Komorbiditäten keine präoperative Darmvorbereitung erhielten, wohl um diese den damit verbundenen Nebenwirkungen nicht auszusetzen. Obwohl die Patienten ohne Darmvorbereitung einen schlechteren ASA-Status hatten, traten bei Ihnen insgesamt weniger Komplikationen auf. Auch der Krankenhausaufenthalt war in dieser Gruppe kürzer. Am Häufigsten wurden tiefe anteriore Rektumresektionen durchgeführt, gefolgt von rechts- und linksseitigen Hemikolektomien sowie Sigmaresektionen. Etwa zwei Drittel der Patienten wurden ausschließlich mit einer primären Anastomose versorgt, 21 Patienten erhielten zusätzlich ein protektives, elf ein endständiges Stoma. Histopathologisch befanden sich die Kolonkarzinome meist im UICC-Stadium 3, die Rektumkarzinome im UICC-Stadium 2. Die häufigsten Komplikationen in der postoperativen Phase waren Erbrechen, Darmatonien und Wundheilungsstörungen. Insgesamt sieben Anastomoseninsuffizienzen wurden beobachtet, vorwiegend nach rektalen Eingriffen. Bei 19 Patienten wurde eine Revisionsoperation notwendig. Präoperativ wurde die Lebensqualität vor allem vom Allgemeinzustand, dem Krankheitsstadium und neoadjuvanten Radiochemotherapien beeinflusst. Meist sank die Lebensqualität und Zufriedenheit postoperativ, was abhängig war von der Art der Operation, Komplikationen und besonders davon, ob ein Kontinenzerhalt möglich war. Etwa ein Fünftel der Patienten berichtete allerdings auch über eine Besserung. Die Erkenntnisse dieser Arbeit lassen, auch unter Berücksichtigung aktueller Literatur, den Schluss zu, dass die Darmvorbereitung in den meisten Fällen verzichtbar ist. Die Rekonvaleszenz nach kolorektalen Operationen wird von zahlreichen Faktoren beeinflusst. Sie zu beschleunigen, Komplikationen zu minimieren und kürzere Krankenhausverweildauern zu realisieren, sind Ziele multimodaler Konzepte wie das der Fast-Track-Chirurgie. Die diesbezüglich insgesamt positive Studienlage wird allerdings dadurch relativiert, dass bisher vorwiegend relativ „gesunde“ Patienten Gegenstand der Untersuchungen waren. Rektumkarzinom-Patienten, bei denen im Allgemeinen viele Komplikationen auftreten, wurden in bisherigen Studien ausgenommen. Um besser auf die Bedürfnisse der Patienten eingehen zu können, ist es wichtig zu wissen, wie Erkrankung und Therapie die Lebensqualität beeinflussen. Auch diesbezüglich ist die Datenlage insgesamt unbefriedigend, so dass weitere Studien unabdingbar erscheinen. / The aim of this prospective study was to examine if colorectal surgery can be performed safely without preoperative mechanical bowel preparation. The patients also were monitored in the postoperative period to identify factors that influence convalescence, quality of life and patient satisfaction.

South Africa is engaged in social redress and Education at all levels reflects this commitment. The period of transition from the apartheid policy of the National Party, (1948 – 1994), to the democratic policy of the African National Congress and its alliances, (1994 - ), continues to be in a state of flux. Education authorities struggle to maintain a balance between widening access to previously disadvantaged students whilst maintaining standards at the same time. Much of the recent debate on good teaching and learning practices suggests that teachers not only need to have a firm grasp of their discipline knowledge but that they also need to perform competently in pedagogic practice. This debate recognises sociological change in knowledge-discourses, fair and transparent assessment policy, and teacher and learner profiles, thereby creating an urgent need for a new professional identity for teachers. Efficient and effective teaching practices require school teachers to be sensitive to innovative and wide ranging culture-sensitive content as proposed by the Revised National Curriculum Statement (RNCS). This is a refined version of South Africa’s first national education policy, C2005, introduced to schools in 1998 and streamlined in 2000 by the Review Committee of C2005 to produce the RNCS. Music now fits into Arts and Culture, one of eight integrated learning areas. The Generalist-Specialist Music Educator is a new identity meant to empower classroom trainee-teachers in primary and secondary education who are new to the discipline of music. The majority of the teacher-trainees who have elected to take the Music in Education module at the University of The Witwatersrand’s School of Education are admitted under discretionary rules, and as a consequence they have little or no experience of formal music education. The Generalist-Specialist Music Educator comes from such a background and her aim would be to fast track her way towards a music orientation that would equip her to advise her own students who might want to learn music at school. Specifically, the Generalist-Specialist should enhance the open relationship between learner and teacher as well as contribute effectively to the multidisciplinary nature of today’s school curriculum.

Internationally as well as in Sweden, efforts for improvement in gynaecological surgery in recent decades have mainly focused on three new treatment concepts: (1) Use of minimally invasive procedures: since there is an interdependency between the extent of surgical trauma and the risk for adverse outcome, increased use of supposedly atraumatic endoscopic procedures has revolutionized several aspects of surgical care (2) A multimodal approach to eliminate harmful procedures in the peri-operative process based on evidence-based principles (3) Introduction of implants to support damaged tissue with synthetic mesh in incontinence and pelvic organ prolapse patients. Research question 1: Is introduction of a minimally invasive operation enough per se or is the measured improvement mediated by elimination of harmful procedures in the perioperative process? Findings: Our study (Paper I) indicates that by applying a multimodal intervention programme for the pre- and postoperative care of patients undergoing supravaginal hysterectomy, the surgical procedure per se is of less importance than generally considered. Patient-related parameters such as length of postoperative hospital stay, number of days at home with need of painkillers, number of days before return to normal activities, and patient satisfaction did not differ between patients undergoing the laparoscopic procedure and patients undergoing abdominal supravaginal hysterectomy. When evaluating a new and presumably improved operative procedure against an established standard procedure, it is mandatory and of fundamental importance that the two methods are aligned in terms of perioperative care provided. Research question 2: Under which circumstances can it be assumed that a new surgical procedure showing promising efficacy in one setting can be reproduced with similar results in a different clinical setting (Paper I)? Findings: The operating surgeons concluded that, in their hands and under local conditions, laparoscopic technique for supravaginal hysterectomy was not superior to traditional open hysterectomy and stopped using laparoscopic technique. It seems necessary, prior to routine use, to monitor, using scientific tools, whether the advantages described in the literature are achievable under local conditions. Research question 3: Do expected advantages of implants outweigh the unwanted effects and complications caused by implants in operations for recurrent cystocele (Paper II)? Findings: Mesh has better durability but more (minor) complications. It is not possible to determine whether mesh is "generally better" than native tissue operation. Some may focus on the improved durability, others on the increased risks. The surgeon must make a risk assessment for each individual case. The patient must be sufficiently informed to understand the risks and make a personal, informed decision whether she wants an augmentation by implant. Essential for this process is a clear, comprehensible picture of both desired and unwanted effects of the planned surgery. In this context, studies like ours might be of use.

No description available.

The basis for this thesis involved a four month Accelerate Canada internship at the Grand River Hospital Emergency Department in Kitchener, Ontario. The Emergency Department (ED) Process Committee sought insight into strategies that could potentially reduce patient length of stay in the ED, thereby reducing wait times for emergency patients. This thesis uses discrete event simulation to model the overall system and to analyze the effect of various operational strategies within the fast track area of the emergency department. It discusses the design and development process for the simulation model, proposes various operational strategies to reduce patient wait times, and analyzes the different scenarios for an optimal fast track strategy. The main contribution of this thesis is the use of simulation to determine an optimal fast track strategy that reduces patient length of stay, thereby reducing patient wait times. Wait times were most significantly reduced when there was an increased physician presence/availability towards the fast track system. This had the greatest impact on the total time spent in the ED and also on queue length. The second most significant reduction to the performance measures occurred when an additional emergency nurse practitioner was supplemented to the fast track system. Accordingly, the nurse practitioner’s percent utilization increased. There was only one two-way interaction effect that was statistically significant in reducing the primary performance measure of wait times; however, the effect did not change the queue length, a secondary performance measure, by a significant amount. Finally, the implementation of a See-and-treat model variant for fast track had a negligible effect on both the average length of stay and queue length.

SAMMANFATTNING Patienter som drabbas av höftfrakturer är en vårdkrävande och utsatt patientgrupp inom sjukvården. Riktlinjer för handläggning av misstänkta höftfrakturer har utformats för ett snabbare omhändertagande, så kallat snabbspår. Dessa används för att optimera och förkorta handläggningstiden, förbättra behandlingen samt minska risken för komplikationer. I Västernorrlands län tillämpas detta snabbspår, vilket medför att delar av den behandling som tidigare utfördes på akutmottagningen, nu utförs av ambulanssjuksköterskor redan i den prehospitala vården. Dessa medicinska och omvårdnadsmässiga åtgärder utförs i varierande och ibland svåra vårdmiljöer. Därför finns ett behov av att studera ambulanssjuksköterskornas upplevelser och erfarenheter av att vårda patienter med misstänkt höftfraktur. Syftet med studien var att beskriva ambulanssjuksköterskors upplevelser och erfarenheter vid omhändertagande av patienter med misstänkt höftfraktur. Kvalitativ ansats användes och designen var semistrukturerade intervjuer som analyserades med kvalitativ manifest innehållsanalys. Studiepopulationen bestod av åtta ambulanssjuksköterskor stationerade i Ångermanland. I resultatet framkom att ambulanssjuksköterskorna innehar både positiva och negativa erfarenheter av att arbeta med misstänkta höftfrakturer. Äldre människor utgjorde den största patientgruppen och dessa patienter led ofta av demenssjukdomar samt andra sjukdomar och tillstånd som försvårade kommunikation och interaktion, vilket skapade svårigheter i handläggningen av dessa patienter. Vårdmiljön försvårade arbetet ytterligare för ambulanssjuksköterskorna och innebar ofta svåra förflyttningar och lyft. Positivt för både patienten och ambulanssjuksköterskorna var att det strukturerade omhändertagandet gav en snabbare vårdkedja och likvärdig vård för patienterna samt mer tid för omvårdnad. Andra aspekter som framkom var att ambulanssjuksköterskorna hade en del förutfattade meningar gällande patientgruppen och svårigheter att få patienten tillräckligt smärtlindrad. Själva omhändertagandet uppgavs vara alltför strukturerad, handläggningen tog lång tid och att det var svårt att få patienten tillräckligt smärtlindrad utan biverkningar. Slutsatsen var att ambulanssjuksköterskorna hade både positiva och negativa erfarenheter kring det strukturerade omhändertagandet, samt en del förutfattade meningar. Samtliga informanter ansåg att de hade mer tid för omvårdnaden och att de på så vis fick lära känna patienten bättre, därför kunde de enklare utvärdera behandlingsresultatet. De positiva erfarenheterna var att omhändertagandet gav en snabbare handläggning med bättre struktur och därigenom en likvärdig vård i hela länet gällande denna patientgrupp. Det accepterades att uppdragen tog längre tid och därför fick personalen även mer tid tillsammans med patienterna. Ambulanssjuksköterskorna kunde se ett konkret resultat av omhändertagandet. De negativa erfarenheterna innefattade att patientgruppen var svårbedömd på grund av eventuella tidigare sjukdomar och läkemedelsbehandlingar. Att anhöriga och vårdpersonal ibland trängde sig in i vårdrummet, med syfte att vara behjälplig, men flyttade istället fokus från patienten. / ABSTRACT Patients with hip fractures are a care-intensive and vulnerable patient population in health care. Guidelines for dealing with suspected hip fractures have been designed for a faster disposal, so-called fast track. These are used to optimize and shorten the processing time, improve treatment and reduce the risk of complications. Västernorrland county has applied a fast track, which means that parts of the processing previously performed in the emergency department, now is performed by ambulance nurses already in the prehospital care. These medical and nursing activities performed in varying and sometimes difficult healthcare environments. Therefore there was a need to study the ambulance nurses' experiences of caring for patients with suspected hip fracture. AIM: The aim of the study was to describe Ambulance nurses experiences of treatment of patients with suspected hip fracture. Qualitative approach was used and the design was semi-structured interviews were analyzed using qualitative manifest content analysis. The study population consisted of eight ambulance nurses stationed in Ångermanland, Sweden. The result showed that ambulance nurses possess both positive and negative experiences of working with suspected hip fracture. Older people represented the largest group of patients and these patients often suffered from dementia and other diseases and conditions that impeded communication and interaction, which created difficulties in dealing with these patients. The healthcare environment complicated the work further for the ambulance nurses and often includes difficult movements and lifting. Positive for both the patient and ambulance nurses was that it structured the care provided faster care chain and equivalent care for patients as well as more time for care. Other aspects that emerged were that the ambulance nurses have some preconceptions regarding the patient group and the difficulties in getting the patient adequate pain relief. The fast track was described to be too structured, the processing takes a long time and that it was difficult to get the patient enough pain relief without side effects. The conclusion was that it emerged that the ambulance nurses had both positive and negative experiences of the structured care, and had some preconceptions. All the respondents felt that they had more time for care, and that they got to know the patient better, because they could more easily evaluate the treatment outcome. The positive experience was that the fast track provided faster processing with better structure and thereby an equal treatment throughout the county regarding this population. It was accepted that missions took longer therefore the staff spent more time with the patients. The ambulance nurses could see concrete result of the fast track. The negative experiences included that the patient group was difficult to assess because of past illnesses and drug treatments. Relatives and caregivers are sometimes forced into the nursing room, with the aim to be helpful, but instead moved focus from the patient.