Clinical learning is regarded as a vital component in nursing programmes and students need to work in various clinical environments. In the emergency nursing programme presented at a tertiary nursing education institution, the pre-hospital environment is used as a clinical learning environment in which students rotate for approximately eight weeks. The clinical experience that they gain may assist in them developing the necessary knowledge and skills. It also assists in theory-practice correlation. The purpose of this study was to evaluate the value of the pre-hospital environment utilised as part of the clinical learning component of the emergency nursing programme. A qualitative approach was utilised since the researcher wanted to study a particular phenomenon, namely the pre-hospital learning environment. Therefore, the research design was a descriptive design whereby the researcher could describe the real life situation in the pre-hospital learning environment as experienced by the emergency nurse students. The target population for the study was emergency nurses who had already obtained their qualification as a registered emergency nurse, as well as emergency nurse students that had completed their rotational period in the pre-hospital learning environment. For the purpose of this study the identified sample consisted of students enrolled for the emergency nursing programme at a tertiary nursing education institution in Gauteng. The sample was adequate to provide the researcher with sufficient in-depth data and was also representative of the accessible population. The final sample size was 45 emergency nurse students who had completed the pre-hospital rotational period between 2008 and 2011. Data collection was done by means of Appreciative Inquiry, a method used that not only focuses on the positive, but which is also a stimulating way of looking at organisational change. Stories (narratives) were shared by the emergency nurse students pertaining to their real life experiences. Initially stories were shared in writing on an Appreciative Inquiry interview schedule. For the purpose of data saturation, individual Appreciative interviews were conducted by an independent interviewer, utilising the Appreciative Inquiry interview schedule as a guide. Data analysis was conducted by the interviewer, supervisors and an independent data analyser to ensure trustworthiness. Four themes were identified, namely clinical exposure, competencies, team work and future recommendations. From the data analysis and the four themes recommendations could be made with regard to programme refinement. Copyright / Dissertation (MCur)--University of Pretoria, 2013. / Nursing Science / unrestricted

Introduction: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is an endovascular technique for temporarily stabilizing hemodynamically unstable patients until permanent interventions can be performed. The benefits of in-hospital REBOA to control hemorrhage in different areas is now well studied, yet little is known about its use and indications in the pre-hospital setting. Aim: The aim of this study is to analyze if mortality amongst trauma patients who receive in-hospital REBOA is affected by total pre-hospital time (TPT) and if earlier prehospital REBOA intervention could be beneficial. Methods: A retrospective analysis using the ABOtrauma registry, an international registry for trauma patients that receive REBOA. There were 314 patients in the registry, 168 patients excluded because of missing data, wrong input, TPT < 15minuts or TPT > 120 minutes. The remaining 146 included were divided into 4 groups. Statistically analyzed using chi-square test for association or binomial logistic regression. Results: We found no significant correlation between TPT and mortality amongst the time groups that received in-hospital REBOA, at the emergency department (p=0.293), at 24 hours (p=0.209) or at 30 days (p=0.385), nor between time of injury and ABO insertion at 24 hours (p=0.917), or 30 days (p=0.840). Conclusion: Our findings suggests that pre-hospital time may not be a good indicator for survival amongst patients that receive in-hospital REBOA and that these patients might possibly have had a similar outcome even if earlier intervention of pre-hospital REBOA was performed. Future prospective randomized controlled trails on the subject is needed to draw certain conclusions.

Bakgrund: Hjärtinfarkt är den främsta dödsorsaken globalt och majoriteten av dödsfallen sker innan patienten har kommit till sjukhus. Hjärtinfarkt är ett livshotande tillstånd där snabb och effektiv behandling kan rädda liv. Utöver fysiskt lidande kan upplevelsen av att drabbas av en hjärtinfarkt påverka patienten på ett existentiellt plan. I den komplexa miljö som prehospital akutsjukvård innebär, behöver ambulansteamet utöver effektiv medicinsk behandling också kunna erbjuda patienten en holistisk omvårdnad.  Syfte: Arbetets syfte var att beskriva patienters upplevelse av att drabbas av en hjärtinfarkt utifrån ett prehospitalt akutsjukvårdsperspektiv.  Metod:  Arbetet antog designen litteraturöversikt med systematisk ansats, där 15 originalartiklar samlats in. 14 av dessa var av kvalitativ design medan en artikel antog designen mixed-methods. Metodologin samt dataanalysen har utförts i enlighet med Polit och Becks niostegsmodell. Databaserna som användes vid datainsamling var PubMed, CINAHL och PsycInfo.  Resultat: Två teman med respektive två subteman togs fram. Från symtomens början var det många som upplevde fysiska såväl som emotionella reaktioner. Symtom kunde vara diffusa och debutera under lång tid och patienterna kämpade med att hitta en orsak till sina symtom. Komplexa symtom och patientens föreställningar gjorde att många väntade med att söka hjälp. Närstående och vårdens bemötande hade också en påverkan i patientens beslutsfattande.  Slutsats: De breda beskrivningarna av symtom, bekräftar tidigare forskning och belyser komplexiteten av detta sjukdomstillstånd inom den prehospitala akutsjukvården. Patientens egna tolkningar, föreställningar och upplevelser påverkade deras beslut att söka vård. I linje med tidigare forskning visades upplevelsen av en hjärtinfarkt kunna orsaka patienter psykologiskt och existentiellt lidande. För att ytterligare fördjupa kunskapen om patientens upplevelse samt kunna omsätta detta till klinisk praxis, föreslås vidare forskning som fokuserar på patientens upplevelse av omhändertagandet inom prehospital akutsjukvård. / Background: Myocardial infarction is the leading cause of death globally and the majority of deaths occur before the patient has arrived at the hospital. Myocardial infarction is a life-threatening condition where quick and effective treatment can save lives. In addition to physical suffering, the experience of suffering a myocardial infarction can affect the patient on an existential level. In the complex environment of pre-hospital emergency care, the ambulance team requires, in addition to effective medical treatment, to be able to offer the patient holistic care. Aim: The aim of the thesis is to describe patients’ experiences of suffering a myocardial infarction from a pre-hospital emergency care perspective. Method: This thesis adopts the literature review design with a systematic approach, where 15 original articles were collected. 14 of the articles adopted a qualitative design, meanwhile one article adopted a mixed-methods design. The methodology has been carried out in accordance with Polit and Beck's nine-steps-model. The articles were collected from the databases PubMed, CINAHL and PsycInfo.  Results: Two themes with two subthemes respectively were produced. From the onset of symptoms, many experienced physical as well as emotional reactions. Symptoms could be diffuse and present over a long period of time, and patients struggled to find a cause for their symptoms. Complex symptoms and the patient's beliefs made many patients wait to seek help. People close to the patient and healthcare providers had an impact on the patient's decision-making. Conclusion: The broad descriptions of symptoms confirm previous research and highlight the complexity of this disease state in prehospital emergency care. The patient's own interpretations, beliefs and experiences influenced their decision to seek care. In line with previous research, it was shown that the experience of a myocardial infarction can cause patients psychological and existential suffering. In order to further deepen the knowledge of the patient's experience and be able to translate this into clinical practice, the authors suggest further research that focuses on the patient's experience of care in prehospital emergency care.

Bakgrund: Akutsjukvården är en väsentlig del av sjukvården där alla möjliga patienter söker sig till. Sjuksköterskan som möter dessa patienter behöver fatta en rad olika beslut med varierande komplexitet. Beslut som är avgörande för liv och död samt berör patienter i deras mest sårbara tillstånd. Syfte: Att belysa faktorer som påverkar sjuksköterskans beslutsfattande i akutsjukvård. Metod: Studien är en litteraturöversikt med artiklar som är både kvalitativa och kvantitativa. 10 artiklar användes för att sammanställa ett resultat. Resultat: Faktorerna som påverkade sjuksköterskans beslutsfattande inom akutsjukvård redovisas genom tre huvudteman: Sjuksköterskans professionella egenskaper, miljöfaktorer och etiska dilemman. Tillsammans med åtta kategorier. Konklusion: Evidensbaserad kunskap är väsentligt för sjuksköterskans beslutsfattande förmåga. Med stöd av erfarenhet och ett personcentrerat förhållningssätt som främjar patientens integritet och värderingar. / Background: Emergency care is a crucial aspect of healthcare that patients seek out to obtain assistance. Nurses who encounter these patients must make important and life-changing decisions in a variety of situations where life and death hang in the balance. Aim: Highlight the factors that influence the nurse’s decision-making in emergency care. Method: This study is a literature review with quantitative and qualitative studies. 10 articles were selected to compile a result. Findings: The study produced three themes: Nurse professional attributes, environment, and ethical dilemmas. Alongside eight categories. Conclusion: Evidence-based knowledge is essential for the nurse's decision-making ability. Supported by experience and a person-centered approach that promotes patient integrity and values.

The increase and changes in the demand for emergency care require pro-active responses from the designers and implementers of the emergency care system. The role of Emergency Care Practitioner (ECP) was introduced in England to improve the delivery of emergency care in the community. The role was evaluated using cost-benefit approach and compared with other existing emergency care roles. An analysis of the cognitive elements (situation awareness (SA) and naturalistic decision making (NDM)) of the ECP job was proposed considering the mental efforts involved. While the cost-benefit approach can justify further spending on developing the role, a cognitive approach can provide the evidence in ensuring the role is developed to fulfil its purpose. A series of studies were carried out to describe SA and NDM amongst ECPs in an ambulance service in England. A study examined decision-making process using Critical Decision Method interviews which revealed the main processes in making decision and how information was used to develop SA. Based on the findings, the subsequent studies focus on the non-clinical factors that influence SA and decision making. Data from a scoping study were used to develop a socio-technical systems framework based on existing models and frameworks. The framework was then used to guide further exploration of SA and NDM. Emergency calls that were assigned to ECPs over a period of 8 months were analysed. The analysis revealed system-related influences on the deployment of ECPs. Interviews with the ECPs enabled the identification of influences on their decision-making with respect to patient care. Goal-directed task analysis was used to identify the decision points and information requirements of the ECPs. The findings and the framework were then evaluated via a set of studies based on an ethnographic approach. Participant observations with 13 ECPs were carried out. Field notes provided further insight into the characteristics of jobs assigned to the ECPs. It was possible to map the actual information used by the ECP to their information needs. The sources of the information were classified according to system levels. A questionnaire based on factors influencing decision-making was tested with actual cases. It was found that the items in the questionnaire could reliably measure factors that influence decision-making. Overall, the studies identify factors that have direct and indirect influences on the ECP job. A coherent model for the whole emergency care systems can be developed to build safety into the care delivery process. Further development of the ECP role need to consider the support for cognitive tasks in light of the findings reported in this thesis.

Background: In Myocardial infarction (MI) it is well established that timely diagnosis and treatment may reduce mortality and improve the prognosis. Therefore it is important that patients with MI seek medical care as soon as possible. Patients with diabetes have a higher risk for MI and worse prognosis compared to patients without diabetes. Previous research is inconclusive regarding symptoms and pre-hospital delay times in MI among patients with diabetes and there is lack of research in how patients with diabetes perceive, interpret and respond to MI symptoms.  Aim: The overall aim of this thesis was to explore symptoms and care seeking behaviour during MI in patients with diabetes.  Methods: This thesis comprises four studies. Studies I and II were based on data from the Northern Sweden MONICA myocardial infarction registry to describe symptoms in 4028 patients (I) and pre-hospital delay and factors associated with pre-hospital delay of ≥ 2 h in 4266 patients (II). Study III included 694 patients, at five hospitals in Sweden. The patients answered a questionnaire about symptoms, response to symptoms and delay times in MI. In study IV data were collected through interviews about experiences of getting MI and the decision to seek medical care.  Results: Study I showed that typical MI symptoms according to MONICA criteria were common in both men and women, both with and without diabetes, and no differences between the groups were found. Study II showed that more patients with diabetes had pre-hospital delay times of ≥ 2 h compared to patients without diabetes. In Study III, chest pain was the most common self-reported MI symptom in patients with and without diabetes and there were no differences between the groups. Shoulder pain/discomfort, shortness of breath and tiredness were more common in patients with diabetes whereas cold sweat was less common compared to patients without diabetes. Less than 40 % of patients with diabetes called the emergency medical services (EMS) as their first medical contact (FMC) and about 60 % initially contacted a spouse after symptom onset. Patients with diabetes reported longer patient delay than patients without diabetes, but after age and gender adjustments the results were not significant. Pain, pressure or discomfort in the stomach, anxiety, symptoms that come and go and thoughts that the symptoms would disappear were associated with longer patient delay in patients with diabetes. In study IV, the analysis revealed the core category “Becoming ready to act” and the categories perceiving symptoms, becoming aware of illness, feeling endangered, and acting on illness experience. Patients with diabetes described a variety of different MI symptoms, the onsets of MI varied and it was sometimes difficult to interpret symptoms as related to MI. The decision to seek medical care for MI was complex with several barriers for timely care seeking.  Conclusion: Chest pain was common in patients with diabetes and in contrast to our hypothesis chest pain was equally common in both patients with and without diabetes. There were more similarities than differences in MI symptoms between patients with and without diabetes. However, patients with diabetes were more likely to have pre-hospital delay for 2 hours or more compared to those without diabetes and there seems to be an underutilization of the use of emergency medical services as first medical contact. The process to seek care for MI was complex, initiated by perceiving symptoms, followed by illness awareness, feelings of being endangered and finally acting on the illness experience. / Bakgrund: Vid hjärtinfarkt är det sedan tidigare väl känt att snabb vård och behandling är viktigt för att förbättra prognosen. Det är därför av stor vikt att patienter med hjärtinfarkt söker vård så snart som möjligt efter att symtomen startat. Patienter med diabetes löper större risk att drabbas av hjärtinfarkt och prognosen efter en hjärtinfarkt är sämre än för patienter utan diabetes. Tidigare forskning har varit ofullständig när det gäller symtom och fördröjning att söka sjukvård vid hjärtinfarkt hos patienter med diabetes. Det saknas också forskning om hur patienter med diabetes uppfattar, tolkar och agerar vid symtom på hjärtinfarkt.  Syfte: Det övergripande syftet med föreliggande avhandling var att utforska symtom och hur man agerar vid hjärtinfarkt hos patienter med diabetes.  Metod: Avhandlingen består av fyra delstudier. Studie I och II baseras på data från norra Sveriges MONICA-hjärtinfarktregister för att beskriva symtom hos 4028 patienter samt pre-hospital fördröjning och faktorer som har samband med fördröjning hos 4266 patienter. Studie III inkluderade 694 patienter från 5 sjukhus i Sverige som alla besvarade en enkät om symtom, agerande och fördröjningstider vid hjärtinfarkt. I studie IV samlades data in via intervjuer som handlade om upplevelsen av att drabbas av hjärtinfarkt och beslutet att söka medicinsk vård.  Resultat: Studie I visade att typiska hjärtinfarktsymtom enligt MONICA kriterier var vanliga hos både män och kvinnor, med och utan diabetes och ingen skillnad mellan grupperna kunde påvisas. Studie II visade att en större andel av patienter med diabetes jämfört med patienter utan diabetes hade pre–hospital fördröjning ≥2 timmar. I studie III var bröstsmärta det vanligaste hjärtinfarktsymtomet hos patienter med diabetes och det var ingen skillnad jämfört med patienter utan diabetes. Smärta/obehag i skulderpartiet, andningsbesvär och trötthet var vanligare hos patienter med diabetes medan kallsvett var mindre vanligt i jämförelse med patienter utan diabetes. Mindre än 40 % av patienterna med diabetes kontaktade SOS alarm som första kontakt med sjukvården och ungefär 60 % kontaktade initialt en partner efter symtomdebut. Patienter med diabetes rapporterade längre fördröjningstider jämfört med patienter utan diabetes, men efter justeringar för ålder och kön var skillnaden inte signifikant. Smärta obehag eller tryck i magen, ångest, intermittenta symtom samt att man trodde att symtomen skulle gå över hade samband med längre patientfördröjning hos patienter med diabetes. I studie IV resulterade analysen i kärnkategorin ”Att bli redo att agera” och kategorierna att uppleva symtom, inse att man är sjuk, känna ett hot och agera utifrån upplevelsen. Patienter med diabetes beskrev en mängd olika hjärtinfarktssymtom, debuten av symtom varierade och det var ibland svårt att tolka symtomen som hjärtinfarkt. Beslutet att söka vård vid hjärtinfarkt var komplext och beslutet fördröjdes på grund av flera barriärer.  Slutsats: Sammanfattningsvis var bröstsmärta vid hjärtinfarkt vanligt och i motsats till vår hypotes lika vanligt hos patienter med som utan diabetes. Det fanns fler likheter än skillnader i hjärtinfarktsymtom mellan grupperna, Patienter med diabetes hade dock längre pre-hospital fördröjning jämfört med patienter utan diabetes. Trots betydelsen av snabb medicinsk vård vid hjärtinfarkt underutnyttjades SOS alarm som första medicinska kontakt. Processen att söka vård för hjärtinfarkt var komplex. Den började med upplevelsen av symtom, följt av insikten att man är sjuk, att man känner ett hot och slutligen agerar utifrån upplevelsen av sjukdom.

Introdução: O Atendimento Pré Hospitalar (APH) tem por finalidade prestar atendimento em situações de urgência e emergência clinica ou traumática, no local do evento e durante o transporte até uma instituição de destino, com o suporte especifico para o tipo de urgência ou emergência. Os trabalhadores da equipe do APH móvel vivenciam situações emergenciais que envolvem constante exposição a materiais biológicos. Considerando a ocorrência de acidentes de trabalho com exposição a material biológico potencialmente contaminado como um dos principais riscos para os trabalhadores da saúde. A escassez de estudos que contemplem o APH, propõe-se o desenvolvimento deste estudo. Objetivo: Elaborar protocolos de prevenção de acidentes de trabalho e de condutas pós-exposição ocupacional a material biológico para trabalhadores de saúde de um serviço de atendimento préhospitalar (APH). Método: Trata-se de uma pesquisa documental, na qual o levantamento de dados foi realizado de duas maneiras: pesquisa bibliográfica e pesquisa documental. A pesquisa bibliográfica foi feita por meio de buscas em bases de dados. A pesquisa foi conduzida em sete fases: determinação dos objetivos; elaboração do plano de trabalho; identificação das fontes; localização das fontes e obtenção do material; tratamento dos dados; confecção das fichas e redação do trabalho; construção lógica e redação do trabalho. O estudo foi desenvolvido no Serviço de Atendimento Móvel de Urgência (SAMU) gerenciado pelo Consórcio Intermunicipal de Saúde da Região Ampliada Oeste do Estado de Minas Gerais (CIS-URG OESTE). O corpus da análise foi representado por periódicos, artigos e dispositivos legais nacionais, estaduais e institucional que regulamentam a Rede de Urgência e Emergência no âmbito nacional. Foram selecionados 104 documentos. A coleta de dados foi realizada no mês de outubro de 2018 e o tratamento dos dados foi de forma sistematizada, organizada, descritiva e analítica. Não houve necessidade de apreciação da Comissão Nacional de Ética e Pesquisa - CONEP para o desenvolvimento deste estudo por não envolver seres humanos. Resultado: Os documentos foram agrupados em duas categorias, permitindo conhecer, delinear e estabelecer os protocolos e fluxos de atendimento aos trabalhadores do SAMU. A primeira categoria de organização do material foi referente a pesquisa bibliográfica. A segunda categoria representou a pesquisa documental; a qual foi subdividida em quatro etapas para análise de toda a legislação nacional, estadual e regional acerca da regulamentação da Rede de Urgência e Emergência no âmbito nacional e o conjunto de documentos sobre a atuação do CIS-URG OESTE. Os dispositivos legais e manuais ministeriais acerca das condutas da promoção da saúde do trabalhador exposto a material biológico no Brasil serviram de embasamento teórico para elaboração de protocolos de prevenção de acidentes e de condutas pósexposição ocupacional a material biológico aos trabalhadores de saúde que atuam no APH do CIS-URG OESTE. Após analises dos referidos documentos, foram elaborados fluxogramas de atendimento aos trabalhadores e os protocolos de ações de prevenção e tratamento imediato em casos de acidentes de trabalho com material biológico neste estudo. Assim este material representa uma produção técnica que será utilizada no CIS-URG OESTE para a promoção da saúde no trabalho. Considerações finais: O trabalho em saúde no APH não é apenas um processo técnico e mecânico, desprovido do caráter humanizante. Representa um conjunto de relações dos diversos atores, um processo complexo cujas condições de trabalho potencialmente, são geradoras de adoecimento. Deste modo, a produção técnica elaborada neste estudo, representa ações técnicas, educativas e de padronização de ações que visam promover a saúde e a qualidade de vida do trabalhador de saúde do APH na Região Ampliada Oeste de Minas Gerais / Introduction: Pre-hospital Care (PHC) is intended to provide emergency and clinical or trauma emergency services, at the event site and during transportation to a destination institution, with specific support for the type of emergency or emergency. The workers of the mobile PHC team experience emergency situations that involve constant exposure to biological materials. Considering the occurrence of occupational accidents with exposure to potentially contaminated biological material as one of the main risks for health workers. The shortage of studies that contemplate the PHC, the development of this study is proposed. Objective: To elaborate protocols for the prevention of occupational accidents and post-occupational exposure to biological material for health workers of a pre-hospital care service (PHC). Method: it is a documentary research, in which the data collection was carried out in two ways: bibliographic research and documentary research. The bibliographic research was done through searches in databases. The research was conducted in seven phases: determination of objectives; preparation of the work plan; identification of sources; location of sources and procurement of material; processing of data; preparation of the fiches and writing of the work; logical construction and writing of the work. The study was developed in the Mobile Emergency Care Service (MECS) managed by the Intermunicipal Health Consortium of the Western Region of the State of Minas Gerais (CIS-URG WEST). The corpus of the analysis was represented by national, state and institutional periodicals, articles and legal provisions that regulate the Emergency and Emergency Network at the national level. We selected 104 documents. Data collection was performed in October 2018 and the data treatment was systematized, organized, descriptive and analytical. There was no need for appreciation of the National Commission for Ethics and Research (CONEP) for the development of this study because it did not involve human beings. Results: The documents were grouped in two categories, allowing to know, to delineate and to establish the protocols and flows of service to the workers of MECS, to wit: first category of organization of the material was referring to bibliographical research; which constituted the synoptic record of the selected primary sources, the second category: documentary research; and this subdivided into four stages or moments referring to the thematic axes; which includes all national legislation that implements and establishes the urgency and emergency network at the national level, the state legislation that implements the emergency and emergency network at the state and regional level, and the set of documents and legislation that constitute the CIS- URG WEST for the management of the emergency and emergency services of the said region and the legal provisions and ministerial manuals that dictates the conduct of prevention, promotion and recovery of workers exposed to biological material, which served as a basis for the elaboration of prevention protocols of accidents and of conducts after occupational exposition to biological material to the health workers that work in the PHC of the CIS-URG WEST. Finals considerations: The work in health in the PHC is not only a technical and mechanical process, devoid of the humanizing character. It represents a set of relations of the various actors, a complex process whose working conditions potentially generate illness. Thus, the technical production elaborated in this study represents technical, educational and standardization actions that aim to promote the health and quality of life of the PHC health worker in the Extended Western Region of Minas Gerais

Bakgrund: Ambulanssjuksköterskan arbetar i en komplex miljö med varierande patientklientel, vilket medför krav på bred kompetens inom många områden. Tidigare forskning påvisar svårigheter gällande omhändertagandet av patienter med psykisk ohälsa i det prehospitala vårdrummet, dock framkommer begränsad mängd forskning i ämnet.Syfte: Att genom ambulanssjuksköterskors erfarenheter beskriva det prehospitala vårmötet mellan ambulanssjuksköterskor och patienter lidandes av psykisk ohälsa samt identifiera eventuella problemområden. Metod: En kvalitativ intervjustudie med induktiv ansats genomfördes. Tio ambulanssjuksköterskor inkluderades genom ett ändamålsenligt urval. Analysen utfördes med hjälp av en kvalitativ, manifest innehållsanalys. Resultat:Ambulanssjuksköterskan kom, i samband med omhändertagandet av patienter med psykisk ohälsa, i kontakt med varierande situationer. I mötet med patienten gav ambulanssjuksköterskan utrymme i såväl samtal som i den fysiska kontakten i syfte att skapa trygghet, lugn och förtroende. Det framkom att en begränsad mängd beslutsunderlag eller riktlinjer fanns att använda i samband med mötet av denna patientgrupp. Slutsats: Att möta patienter med psykisk ohälsa är en komplex situation med många faktorer att ta hänsyn till. En av ambulanssjuksköterskans viktigaste omvårdnadsåtgärder, är att skapa förutsättningar för att etablera ett förtroende hos patienten, i syfte att kunna bedöma och validera patientens hälsotillstånd på bästa möjliga sätt. De bedömningsunderlag och riktlinjer ambulanssjuksköterskan hade tillgång till var begränsade, vilket medförde önskemål om att det utveckla sådana för att tydliggöra vården gällande denna patientkategori. / Background:Ambulance nurses work in a complex environment and encounter a variety of different patient clientele, which requires a broad competence. Previous research indicates difficulties regarding the care of patients with mental illness in the prehospital care setting, though limited amount of research on the subject is available. Aim:To describe ambulance nurses’ experiences of meeting patients suffering from mental illness and to identify possible problem areas. Method:The study is a qualitative interview study with an inductive approach. Ten ambulance nurses were included through a purposeful sample. The results were analysed with a qualitative content analysis.Results: Ambulance nurses were exposed to various situations such as suicide attempts as well as threats. Furthermore, it emerged that the ambulance nurses in the meeting with the patient gave space in both conversation and in the physical contact to create a calm and confident environment. It was found that a limited number of guidelines were available to help the ambulance nurses in the meeting with the patients. Conclusion:Meeting patients with mental illness is a complex situation with many factors to consider. It is of importance to the nurses to create an environment that will enable them to establish patients’ trust. Assessment guidelines that ambulance nurses in this area exist but are limited, therefore it is requested that such are developed further in order to clarify the care regarding this category of patients.

En-dehors des horaires d’ouverture des cabinets de médecine générale, la permanence des soins ambulatoires (PDSA) est assurée par des médecins effecteurs mobiles (MPDSA), missionnés par le SAMU – Centre 15 et effectuant des visites au domicile des patients. L’ordre de réalisation de ces visites est basé sur un modèle intuitif, défini selon le degré d’urgence établi lors de l’appel au SAMU – Centre 15 et la connaissance du secteur par le MPDSA. Cette méthode intuitive est le plus souvent dictée par la problématique du plus court chemin entre les visites. Le maintien de délais compatibles avec le besoin médical dépend ainsi du flux de visites et du temps d’acheminement des MPDSA. Or, ce temps d’acheminement dépend notamment des effectifs de MPDSA de garde et des conditions de trafic. Les modèles existants d’optimisation des trajets sont inapplicables à la PDSA, en raison de la réactualisation continue de la liste des visites à effectuer, ainsi que de la pondération du délai cible par le degré d’urgence.Nous proposons donc de créer un modèle spécifique d’optimisation des trajets des MPDSA missionnés par le SAMU–Centre 15. Nous développons une méta-heuristique évolutionnaire de type algorithme génétique, dont nous comparons d’abord les performances calculatoires à celles d’une méthode exacte d’optimisation linéaire en nombres entiers (méthode d’optimisation combinatoire non évolutionnaire), sur données théoriques, intégrant les données cliniques (3 degrés de priorité de visite), opérationnelles (taille de la flotte des MPDSA) et les objectifs temporels (3 délais d’effection cible). Les objectifs de ce travail sont de montrer que l’algorithme génétique, comparativement à la méthode linéaire en nombres entiers, conduit à une réduction des délais d’effection des visites MPDSA, donc à un plus grand respect des délais d’effection cibles ainsi qu’à une augmentation du nombre de patients vus par unité de temps (plage horaire de PDSA). Les résultats obtenus suggèrent que l’algorithme génétique est à la fois plus performant que la méthode linéaire en nombres entiers sur tous les critères établis, et que ses performances s’améliorent avec la complexité du problème à résoudre (nombre de patients à visiter, taille de la flotte des MPDSA).L’utilisation de la méthode d’optimisation développée dans ce travail pourrait permettre aux SAMU-Centres 15 d’améliorer le service rendu à la population, en termes d’accès au juste soin et de sécurité du patient. / During out-of-hours times, mobile general practitioners (GPs), appointed by the SAMU - Centre 15 (French public emergency call center), can provide out-of-hours home visits (OOH-HV).The order in which these visits are carried out is based on an intuitive model, i.e. the shortest path problem, and determined according to the degree of urgency established at the time of the call to the SAMU - Centre 15 and the knowledge of the sector by the mobile GP. Maintaining timelines consistent with the medical need thus depends on the flow of visits and the GP’s response times. However, this transit time depends in particular on the number of available GPs and traffic conditions. Existing models for routing optimization are inapplicable to OOH-HV, due to the continuous updating of the list of visits to be carried out, as well as the weighting of the target time by the degree of urgency.We therefore propose to create a specific model for the optimization of the mobile GPs’ sent by the SAMU-Centre 15. We develop an evolutionary meta-heuristic of the genetic algorithm type, whose computational performances we first compare with those of an exact method of integer linear optimization (non evolutionary combinatorial optimization method), on theoretical data, integrating the clinical data (3 degrees of priority of visit), operational constraints data (mobile GPs’ fleet size) and response times objectives (3 target effection times). The objectives of this work are to show that the genetic algorithm, compared to the integer linear method, leads to a reduction in mobile GPs visit completion times, to a greater respect of the deadlines of target outcomes, as well as an increase in the number of patients seen per time unit (GPs time slot).Our results suggest that the genetic algorithm is more efficient than the integer linear method on all established criteria, and that its performances improve with the complexity of the problem to be solved (number of patients to visit, size of mobile GPs’ fleet).The use of the optimization method developed in this work could enable the SAMU-Centres 15 to improve the service provided to the population, in terms of efficiency, safety and quality of access to care.

O município de Ribeirão Preto - SP, disponibiliza atenção pré-hospitalar pública através do Serviço de Atendimento Móvel de Urgência (SAMU) e de forma pioneira realiza teletriagem dos chamados de urgência em sua Central de Regulação. Assim, considerando que a teletriagem primária é um complexo método utilizado para garantir segurança, agilidade e eficácia às solicitações de socorro, apresentou-se esta proposta de investigação cujo objetivo foi verificar a aplicação da avaliação multifatorial do grau de urgência, através do mapeamento das teletriagens realizadas pela Central de Regulação do SAMU na cidade de Ribeirão Preto - SP em 2014. Neste sentido, o presente estudo se caracteriza como de abordagem quantitativa, modelo não experimental, retrospectivo, correlacional descritivo e de corte transversal, onde foram analisadas teletriagens primárias(n =2100) realizadas pela Central de Regulação do SAMU em 2014 e foi desenvolvido em quatro etapas: a primeira com uma revisão integrativa da literatura com 21 estudos primários e as demais com o interesse de descrever através do geoprocessamento a análise relacional entre as teletriagens pré-hospitalares da amostra e os fatores etiológicos, que justificam seu arranjo espacial, os casos selecionados foram submetidos a avaliação multifatorial do grau de urgência para posteriormente comparar com as distribuições espaciais encontradas, apresentando coeficiente Kappa = -0,0538. Ao final, houve comparação entre as diferentes configurações espaciais disponíveis e comprovou-se que não há evidencias da utilização da avaliação multifatorial do grau de urgência, nas amostras selecionadas para esta investigação, de teletriagens primárias do SAMU de Ribeirão Preto - SP em 2014, com base no raciocínio estatístico adotado e sob a ótica do geoprocessamento. Com isso, este estudo contribui para o monitoramento das triagens e, consequentemente, favorece o raciocínio dos fluxos do sistema, propondo o realojamento de unidades móveis de atendimento, a criação de mais equipes de suporte avançado, o engajamento em pesquisas de delineamento metodológico para desenvolver protocolos específicos para teletriagem pré-hospitalar no Brasil e tecnologias que apoiem e facilitem todo o processo / The city of Ribeirão Preto in SP, offers public pre-hospital care through the Mobile Emergency Service (SAMU) and a pioneer performs teletriage of so-called urgency in his Central regulation. Thus, considering that the primary teletriaging is a complex method to ensure safety, speed and efficiency to rescue requests, we presented this research proposal aimed to verify the application of multifactorial assessment of the degree of urgency, by mapping the teletriage made by SAMU Regulation Center in Ribeirão Preto - SP in 2014. in this sense, the present study is characterized as a quantitative approach, not experimental, retrospective design, descriptive correlational and cross-sectional, where primary teletriage were analyzed (n = 2100) conducted by the SAMU Regulation Center in 2014 and was developed in four stages: the first with an integrative literature review 21 primary studies and the other in the interest of describing through geoprocessing relational analysis between pre teletriage pre-hospital sample and etiological factors which justify their spatial arrangement; the selected cases were submitted to multifactorial assessment of the degree of urgency to later compare the spatial distributions found, with Kappa = - 0.0538 coefficient. At the end, there was a comparison between the different spatial configurations available and it was shown that there is no evidence of use of the multifactorial assessment of the degree of urgency, in the samples selected for this research, primary teletriagens SAMU of Ribeirão Preto - SP in 2014, with adopted based on statistical reasoning and from the perspective of geoprocessing. Therefore, this study contributes to the monitoring of trials and consequently favors the reasoning of system flows, proposing the relocation of mobile service units, the creation of more advanced support teams, engaging in methodological design of research to develop specific protocols for pre-hospital telescreening in Brazil and technologies that support and facilitate the process