A new realm of discourse research has started examining medical interactions in the crowded space – hospitals (Iedema, 2007). Beyond clinical settings and dyadic doctor-patient interactions, scholars have begun investigating doctors’ interactions in various hospital settings including Emergency Rooms and hospitals’ wards (e.g., Eggins & Slade, 2012; Slade & Eggins, 2016; Slade et al., 2015). Other investigations have expanded this scope of discourse research to include other health professionals, such as nurses (e.g., Staples, 2015). Drawing on discourse analytic approaches (Critical Discourse Analysis, Halliday’s Systemic Functional Grammar, and Interactional Sociolinguistics), this study examined nurse-to-nurse handoff interactions in two hospitals in Saudi Arabia. Nursing handoff – the transfer of patient information, professional responsibility, and accountability between departing and incoming nursing teams (Manser et al., 2010; Riesenberg et al., 2010; Slade & Eggins, 2016; Wood et al., 2014) – is a critical communicative practice which ensures the continuity and quality of care provided to hospitalized patients. The aim of this study was to provide detailed analyses of the language used in this type of nursing discourse and its impact on the quality of handoffs. The data included 80 nursing handoff interactions, which were observed and audio-recorded in 7 different wards at two sectors (National Guard Hospital and King Fahad General Hospital) in Saudi Arabia including: Intensive Care Units, General-Adult, General- Pediatric, Oncology-Pediatric, Oncology-Palliative, ENT, Urology and Surgical wards. The nurse participants come from various cultural backgrounds including Philippines, Indonesia, India, Malaysia, Morocco, South Africa, Egypt, Jordan, and Saudi Arabia. The analyses provided a detailed description of this type of nursing discourse including the discourse pragmatic features (i.e., linguistic, interactional, and interpersonal features) which nurses use while delivering and receiving patient information. In addition, the findings provide insights into the various discourse features that contributed either positively (e.g., using discourse markers, presenting complete thoughts, presenting sufficient detailed patient information) or negatively (e.g., producing questions instead of statements, shifting verb tenses, focusing on one patient issue as opposed to providing detailed patient information report) to the nursing handoff practices in this setting. The findings also point to the vital role that head nurses play in this nursing discourse and its impact on enhancing the quality of nursing handoffs. Additionally, a six-stage nursing handoff model was developed from the data, which could be used for nursing training in the National Guard Hospital and its branches in Saudi Arabia. Finally, the findings provide further support for Eggins and Slade’s (2012) claim that communicatively effective handovers are achieved interactionally and with the collaboration of both departing and incoming teams. Furthermore, the use of standardized protocols (like SBAR) alone proved to be insufficient in guaranteeing effective nursing handoff.

Abstract Handoff is the procedure providing the connection to the backbone network while a mobile terminal is moving across the boundaries of coverage of two wireless points of connection. The complexity of the handoff decision process has led to the examination of a number of traditional and pattern recognition handoff decision algorithms for wireless networks. Traditional algorithms use a received signal strength measurement and an optional threshold, hysteresis, or a dwell timer to determine the handoff decision. Degradation of the signal level, however, is a random process, and simple decision mechanisms result in a ping–pong effect whereby several consecutive handoffs degrade the service provided by the network. Consequently, more complex pattern recognition algorithms are needed to decide on the optimal time for handoff. In these algorithms, the handoff decision receives off line training to create a reference database of possible handoff locations in an environment with an associated handoff "fingerprint" at those locations. This dissertation introduces newly designed neural network and adaptive network based fuzzy inference system (ANFIS) pattern recognition algorithms. To select appropriate algorithms for a specific wireless network, we need to create an analytical framework for performance evaluation. The design of a framework for comparative performance evaluation of different handoff algorithms is a complex problem as different networks have different performance evaluation criteria. This dissertation divides wireless networks into three categories according to their topology and wireless service application: traditional cellular phone networks, heterogeneous wireless data networks, and rate adaptive wireless data networks. For each category of wireless networks we define a performance evaluation scenario and using Monte Carlo simulations, Monte Carlo calculations, and direct mathematical analysis we analyze the effects of different handoff decision algorithms. The Manhattan micro-cellular scenario is used for traditional cellular phone networks. Using Monte Carlo simulations on this scenario, the performance of traditional and our neural network and ANFIS handoff decision algorithms are compared. A moving-in moving-out performance evaluation scenario for heterogeneous wireless data networks is defined to characterize intertechnology roaming between two networks with substantially different data rates. We use Monte Carlo calculations to define the optimum handoff location for a mobile terminal in this scenario. Using Monte Carlo simulations and the optimal handoff location, we perform comparative performance evaluation of newly introduced asymmetric traditional and pattern recognition algorithms designed for intertechnology handoff. Finally, we introduce two performance evaluation scenarios for rate adaptive wireless networks to characterize user mobility in rate adaptive networks with random and grid deployments. For the first scenario we provide mathematical analysis for the effects of handoff using relative power to calculate the average throughput observed by the mobile terminal for different distances between the two wireless points of connection. For the second scenario designed for grid deployment we present a comparative performance analysis using Monte Carlo calculations for four handoff decision algorithms.

Inledning: En patientsäker vård bygger på korrekt information och att den informationen överförs på ett tillfredsställande sätt för att inga viktiga delar ska missas. Vårdprocessen är komplex och innehåller många viktiga bitar som behövs för en patientsäker vård. Vid omhändertagandet av en kritiskt sjuk patient arbetar vårdpersonalen ofta i team bestående av olika specialiteter och yrkeskategorier, vilka är beroende av en effektiv kommunikation och god samarbetsförmåga. En kritiskt sjuk patient flyttas ofta mellan olika enheter och vårdkedjan innebär ofta många överrapporteringar utmed vägen. Vid varje överflyttning finns en risk att något missas som kan få konsekvenser för den fortsatta vården. Syftet med den här studien var att identifiera riskfaktorer för patientsäkerheten vid överrapportering av kritiskt sjuka patienter. Metod: Författarna har använt sig av integrerad litteraturstudie för att kunna använda olika typer av studier. Resultat: Studiens resultat presenteras i fyra kategorier: Störningar, Brister i organisationen, Avsaknad av struktur för överrapportering och Samarbetssvårigheter. Konklusion: Riskfaktorer för patientsäkerheten vid överrapportering innefattar olika typer av störningar såsom bullrig miljö och avbrott i rapporten. Brister i organisationen yttrade sig som ett missnöje över att det inte gavs utrymme att förbereda sig och utföra överrapporteringen optimalt. Själva överrapporteringen verkade sakna struktur, en del använde checklistor andra improviserade rapporten. Vårdpersonalen tycktes även sakna ett gemensamt språk och hade en bristande respekt och förståelse för varandras arbetsuppgifter. / Introduction: Correct information and safe transmission of information without information loss are necessary for patient safety. The care process is complex and consists of many important pieces needed for a patient safe care. While caring for a critically ill patient, the caregivers often work in teams consisting of different medical specialties and disciplines. They are depending on an effective communication and smooth cooperative ability. A critically ill patient is often transmitted to several different units along the caregiving pathway. At every transmission there is a risk of information loss that may result in consequences during further caregiving process. The Aim of this study was to identify risk factors for patient safety at the handover of critically ill patients.  Method: This is an integrative review, which is a method for literature review that allows the use of different types of studies. Result: The result of this study is presented in four categories: Interruptions, Organization flaws, Lack of structure for handover and Cooperative difficulties. Conclusion: Risk factors for patient safety during handover included interruptions such as noisy environment and disruptions. The studies showed a dissatisfaction with the lack of space and time for preparation and to perform the handover optimally. The handover seemed to lack structure. Some used checklists, others improvised the handover. They seemed to be missing a common language and also a lack of respect and understanding for each other’s work assignments.

Bakgrund: Det förekommer brister i överrapportering från ambulanssjuksköterska till sjuksköterska på akutmottagning, vilket kan leda till negativa konsekvenser för patienten. Överrapportering är en stor riskfaktor inom vården, vårdskador hade kunnat undvikas genom informativ överrapportering. Tidigare forskning belyser brist på patientsäkerhet, sekretess samt kommunikation under överrapportering. Standardiserade kommunikationsverktyg anses stärka kvalitén på överrapportering. Syfte: Syftet var att undersöka faktorer av betydelse för överrapportering mellan ambulanssjuksköterska och sjuksköterska på akutmottagning. Metod: Kvalitativ intervjustudie med induktiv ansats. Tio semistrukturerade intervjuer genomfördes med ambulanssjuksköterskor och sjuksköterskor på akutmottagning. Intervjuerna analyserades genom Graneheim och Lundmans kvalitativa innehållsanalys. Resultat: Resultatet presenteras i tre huvudkategorier och åtta underkategorier. Bristande sekretess var framträdande och härleddes till miljöns utformning. Sjuksköterskor på akutmottagningen upplevde ibland svårigheter att fokusera enbart på överrapporteringen där hög stressnivå och hög arbetsbelastning var de främsta bidragande orsakerna. Det som ansågs positivt och kunde gynna god och säker överrapportering var att få patienten delaktig, samt använda ett strukturerat kommunikationsverktyg såsom SBAR. Sjuksköterskorna inom båda yrkeskategorierna påpekade fördelen med att förstå varandras arbetssituation och att det bidrog till en ömsesidig respekt. Slutsats: Sekretessen under överrapporteringen är bristfällig, miljön är en stor bidragande faktor. Överrapportering sker vanligen i öppna miljöer med många avbrott och störande moment, vilket gör att sjuksköterskorna känner sig stressade. Brister i överrapportering förekommer och medför att viktig information om patienten går förlorad. Överrapportering önskas genomföras enligt ett strukturerat arbetssätt såsom SBAR i lugna och ostörda miljöer. Miljön behöver förbättras på akutmottagningar så att patientens integritet bibehålls. Fortsatt forskning behövs kring fenomenet överrapportering för att gynna patientsäkerheten samt personalens arbetsmiljö.

This report is the result of a masters degree project conducted at the Department of Teleinformatics at the Royal Institute of Technology starting from the autumn 1996. The area investigated is the Mobile Internet Protocol, especially its implementation under Windows NT environment. Network driver writing under Windows NT was practised. Recent development in improving Mobile IP protocol to support micro-mobility have also been investigated.

Nomadic computing aims to be a leading short term revolution in the Internet, however to succeed in this the infrastructure, the protocols, the handoff mechanisms have to be designed and implemented to provide mobile computing with both reliability and transparency. A good deal of the work is addressed by mobile IP itself, but addressing wireless diversity is perhaps the most important next step. Many different wireless technologies are available; while one technology might provide wide coverage, another provides higher bandwidth, but can only be deployed locally, even uni-directional ad-hoc links can be used to carry IP traffic. To take full advantage of the potential infrastructure, a mobile device, with multiple network interfaces, should be able to dynamically switch from one link technology to another; hopefully totally transparently to the user. Moreover, having multiple interfaces allows the device to choose, each time a new connection is established, which interface to select to route the datagrams through, based on the type of service desired. In this thesis a possible solution is presented, involving both vertical handoff optimization and policy management. Our testing device is the the SmartBadge v4, provided with a GPRS link and a 802.11b WLAN interface. / Nomadic Computing har för avsikt att revolutionera dagens Internet tillämpningar. För att lyckas måste dock infrastrukturen, IT protokollen och handoff procedurer utformas och implementeras med intentionen att förse mobilt dataöverföring med både driftsäkerhet och autonoma processer. En stor del av de nödvändiga förutsättningarna är tillgängliga tack vare Mobile IP, men mångfalden inom de befintliga Wireless teknologierna utgör fortfarande ett problem. Det stora antalet disponibla Wireless tekniker varierar från teknologierer som förser användaren med en stor täckningsgrad, till sådana som förser användaren med högre bandbredd, begränsad till lokala anv ändningområden. Även Uni-directional ad-hoc links kan läggas i denna lista av mångfald. För att förverkliga fördelarna med den tänkta infrastrukturen fullt ut måste den mobila enheten kunna utföra omkopplingar från den ena wireless teknologin till den andra, med syftet att vara osynlig för användaren. Utöver detta är det meningen att en apparat med många anslutningar ska kunna välja den anslutning som passar bäst, var gång en ny koppling ska göras, beroende på den tjänst som efterfrågas. Det här examensarbetet presenterar en möjlig lösning, som utnyttjar både Vertical Handoff optimering och Policy Management. Prototyp-enheten vi anv änder oss av för att genomföra undersökningen är Smart Badge v4, utrustad med GPRS och 802.11b Wireless LAN anslutningar.

Despite some improvement, no consensus exists to perfect quality in anesthesia handoff practice and policy. This quality improvement project was designed to assist a local anesthesia and perioperative workforce questioning the quality of its current handoff. Theories and models used to inform the project included the Inter-Professional Team Collaborative, Lewin's change theory, the continuous quality improvement theory, and the knowledge to action model. The communication assessment tool (CAT) functioned as a needs assessment yielding a gap in handoff practice of 25 participants. The CAT also served as the post project evaluation survey. The situation, background, assessment, and recommendation (SBAR) tool was preferred. Participants received SBAR education, and clinical evaluation experience (CEX) survey training. The CEX described the quality indicators of participant handovers during four consecutive weeks. Descriptive and inferential statistics used to analyze data collections included means and standard deviations, examining trends in the continuous level variables. Reliability of the CAT variables was evaluated through Cronbach's alpha test of internal consistency. Inferential analyses included independent sample t tests, Pearson correlations, and analyses of variance (ANOVAs). Statistical significance was evaluated at the conventional level, α = .05. The use of the SBAR handoff tool showed parity in communication competency. Quality indicators of overall handoff remained highly satisfactory. Recommendations include the consensual use of SBAR handoff and competency evaluation across the anesthesia community. Modification of handoff practices and policies will enable social change by promoting quality indicators in anesthesia collaborative communication.

No description available.

A handoff requires that the responsibility for patient patient’s care is transferred from one healthcare professional to another. The goals of this research were to identify, evaluate, and use analytical methods to describe how physicians (n=10) extracted information from electronic progress notes, one important source of information used during handoffs. Participants also verbally summarized the notes as they would during handoffs. Six methods were used to analyze how participants read progress notes, each uniquely contributing to our understanding of physicians’ visual attention patterns during this process. The participants focused their visual attention on the Impression and Plan section of the progress notes in that over 60% of the participants’ total time was spent reading that section. Physicians could miss an error or critical piece of information if the information is not located in the Impression and Plan. The importance given by the participants to the Impression and Plan section was confirmed in that the majority of participants’ verbal handoff content focused primarily on information that could be found in the Impression and Plan. Participants relied on the Medication Profile section quite heavily if it was present in the progress note. We determined that if the participant was currently reading in one section (s)he most likely would transition his/her visual attention to the physically closest section in the note, meaning the format of progress notes may dictate how notes are read. We determined what the most likely paths were through the progress notes, which could be a first step in reordering of the progress note for evaluation in future studies. Participants’ responses to debriefing questions suggested that they were aware of their reliance on the Impression and Plan, but that they thought the way they read notes is context-specific, depending on factors such as their use of the note and the reputation of the author of the note. These findings suggest a need for more research that evaluates how different note structures and content affect how physicians and other health providers extract and use information in varied clinical contexts.

God kommunikation är kvalitetssäkring av god vård. Vid patientöverlämning prövas kommunikationen och det föreligger risk att information faller bort eller tolkas olika. Det har visats i tidigare studier att vårdskador uppkommit på grund av bristande kommunikation och att inom akutsjukvården är risken än högre för patientsäkerhetsincidenter. Med hjälp av olika kommunikationsverktyg har svensk sjukvård eftersträvat att öka patientsäkerheten vid överlämnande av patient, varav det mest vedertagna är SBAR som står för Situation, Bakgrund, Aktuellt och Rekommendation. Syftet med denna studie var att beskriva hur kommunikationsverktyget SBAR påverkar patientsäkerheten vid överlämnandet av patient inom akutsjukvården. Metoden för studien var en litteraturöversikt med en systematisk ansats med både kvantitativ och kvalitativ design. Litteratursökning utfördes systematiskt i databaserna CINAHL och PubMed och data analyserades utifrån Bettany-Saltikov och McSherrys standardiserade integrerade analysmetod. Resultatet presenterades i tre kategorier vilka var: Kvalitativ överlämning med SBAR, Patientsäkerheten ökade med SBAR och Överlämningstiden förlängdes utan att påverka patientsäkerheten. Samt två underkategorier: SBAR ökade kvaliteten på patientöverlämningen och Strukturen påverkade patientöverlämningens kvalitet. SBAR gav en förbättrad och mer patientsäker patientöverlämning men överlämningsstrukturen påverkades både positivt och negativt samt tidsåtgången för patientöverlämnandet ökade.  Studiens slutsats var att SBAR i stor utsträckning ökade patientsäkerheten genom att ge en mer kvalitativ patientöverlämning och genom att förbättra mätbara och upplevda patientsäkerhetsaspekter. Likväl gav SBAR också viss negativ påverkan på patientsäkerheten. / Good communication is quality assurance of good care. During patient handover communication is tested and there is a risk that information is lost or interpreted differently. It has been shown in previous studies that healthcare injuries occur due to a lack of communication and that in emergency healthcare the risk is even higher for patient safety incidents. With the help of various communication tools Swedish healthcare has strived to increase patient safety when handing over patients, of which the most accepted is SBAR which stands for Situation, Background, Assessment and Recommendation. The purpose of this study was to describe how the communication tool SBAR affects patientsafety during the handover of patients in emergency healthcare. The method for the study was a literature review with a systematic approach with both quantitative and qualitative design. A literature research was systematically performed in the CINAHL and PubMed databases and the data were analyzed based on Bettany-Saltikov and McSherry's standardized integrated analysis method. The results were presented in three categories which were: Qualitative handover with SBAR, Patient safety increased with SBAR and Handover-time was extended without affecting patient safety. As well as two subcategories: SBAR increased the quality of patient handover and Structure affected the quality of patient handover. SBAR provided an improved and more patient-safe patient handover but the handover structure was affected both positively and negatively and the time required for patient handover increased. The study's conclusion was that SBAR increased patient safety to a large extent by providing a more qualitative patient handover and through measurable and perceived patient safety aspects. Nevertheless SBAR also had some negative impact on patient safety.