Delay to antibiotic treatment of community-acquired pneumonia (CAP) greater than 4 hours following hospital admission is associated with a 15% increase in mortality. Paper-based guidelines have been widely introduced to improve CAP care, but these interventions have under-performed due to poor compliance in complex clinical workflows. Unlike passive paper-based guidelines, alerting systems based on computer-based decision support systems (CDSS) have the capacity to actively draw attention to delayed clinical processes. Formal consideration of local workflow is key to the design and successful implementation of CDSS. I used workflow analysis techniques to develop an evidence-based alerting system designed to reduce the delay to treatment of CAP in the emergency department (ED) of an Australian tertiary hospital. A sample of 6 CAP patients were observed during October 2001 to derive a structural process flow model, which was refined via stakeholder interview. A deterministic process flow model was then developed using an existing retrospectively compiled CAP database, consisting of 246 patients admitted June-December 1998 and 146 patients admitted May-December 2000. A stratified control sample presenting with respiratory symptoms (n=74, January-December 2003) was collected for the assessment of diagnosis and chest x-ray (CXR) accuracy. Treatment delay greater than 4 hours was associated with failure to diagnose CAP in the ED, the absence of CXR evidence, low triage score, delayed CXR, and failure to treat in the ED. ED physicians only identified 54-57% of those discharged with CAP. Radiologists only reported CAP features in 47% - 67% of initial CXRs for these patients. I hypothesised that a CDSS-based alerting system, composed of a CAP early diagnosis model (EDM) and a simple risk model (CRB-65), would identify enough CAP patients to reduce the percentage treated after 4 hours. I constructed an evidence-based naïve Bayesian EDM (sensitivity = 36%, specificity = 93%). It was able to identify 24% of CAP patients that died in hospital, 38% of those with antibiotics delayed greater than 4 hours, and 26% of those with CXR delayed greater than 4 hours. CAP-specific risk models were equivalent to the Australasian Triage Score (ATS) in predicting mortality. I simulated alerting policy by combining the CDSS with the deterministic process flow model. Alerting for treatment at triage or initial physician assessment, when the EDM was positive, approximately halved the median treatment time of 5.53 hours, and decreased the number treated after 4 hours (62%) by 1/3. Treating EDM-positive patients as ATS category 2 produced a similar effect. Current triage practices, embodied mainly by the disease-independent, sign and symptom based ATS are too coarse to deal with conditions such as CAP, where there is high diagnostic uncertainty and delays in diagnosis and treatment are critical determinants of outcomes. Better outcomes may be achieved with quicker diagnostic and treatment workflows via: analysis of current diagnosis and treatment workflows, analysis and correlation of a comprehensive set of patient symptoms, signs and risk factors for the specific disease, and improving triaging and subsequent workflow through a disease-specific CDSS based on early diagnostic models derived from the previous analyses. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1374804 / Thesis (Ph.D.) - University of Adelaide, School of Medicine, 2009

Telefonen har under de senaste årtiondena blivit ett viktigt redskap i hälso- och sjukvårdens arbete med människor som söker hjälp och råd för medicinska problem. Telefonlinjer till Sveriges vårdcentraler inrättades allmänt på 1970-talet. En betydande del av sjuksköterskornas arbete på vårdcentral består av telefonrådgivning. Den vårdsökande prioriteras och hänvisas till rätt vårdnivå utifrån den bedömning som görs vid dessa samtal. Syftet med studien är att få kunskap om vad sjuksköterskorna upplever när den vårdsökande inte kan beredas tid trots ett medicinskt behov, då läkartiderna inte räcker till på grund av brist på allmänläkare. Tio sjuksköterskor som arbetar med telefonrådgivning på vårdcentral intervjuades. Studien utfördes med en kvalitativ metod med fenomenologisk ansats. I resultatet framkommer att informanterna har flera olika känslomässiga upplevelser. Informanterna upplever att de inte alltid kan uppfylla det vårdgarantin lovar, men att problemet är organisationsrelaterat och ligger utanför deras egen kontroll. Telefonarbetet kan kännas betungande och tanken på hur det går för den vårdsökande finns ibland kvar efter arbetsdagens slut. Erfarenhet och kunskap anses viktigt för att bättre kunna hantera situationen och göra rätt bedömning. Det kollegiala stödet framhålls som betydelsefullt. Det anses viktigt att noggrant dokumentera givna råd och vilka åtgärder som planerats. / During the past decades the telephone has become an important tool in the healthcare system when people seek help and advice for medical problems. Telephone lines to all healthcare centres in Sweden were established in the 1970´s. A large part of nurses´ work at a healthcare centre consists of giving telephone advice. The callers´ medical needs are assessed and the callers are referred to the proper level of care. The aim of this study is to find out what nurses experience when the caller cannot be given an appointment, despite a medical need for one, because there are insufficient medical appointments available due to a shortage of general practitioners. Ten nurses working with telephone advice at healthcare centre were interviewed. The study was done with a qualitative method using a phenomenological approach. Results indicate that the informants have several different emotional experiences. The informants experience that they cannot always live up to the care guarantee, but that the problem is organizational and beyond their control. Sometimes telephone work feels heavy, and thoughts of how things go for the caller can continue when the work-day is finished. Experience and knowledge are considered important in order to be able to handle the situation better and to make a correct assessment. Support from colleagues is pointed out as meaningful. It is considered important to carefully document the advice given during the telephone call and which measures are planned.

Sjukvårdsrådgivningen via telefon är väl förankrat hos Sveriges befolkning då det varje år rings många samtal dit. Avsaknaden av visuell kontakt och den begränsade tillgången till problemet gör att triage och rådgivning försvåras. Telefonsjuksköterskan kan inte ta del av den icke verbala kommunikationen såsom exempelvis ansiktsuttryck, kroppshållning eller sjukdomstecken på kroppen. Syftet med denna litteraturstudie var att belysa faktorer som har betydelse för telefonsjuksköterskans triage och rådgivning i kontakt med den vårdsökande. I litteraturstudien som grund för resultatet har metoden varit att granska fjorton artiklar med kvalitativ ansats ur ett sjuksköterskeperspektiv. Resultatet visar att telefonsjuksköterskans triage och rådgivning påverkas av olika faktorer som är relaterade till den vårdsökande, telefonsjuksköterskans egna färdigheter och erfarenheter samt faktorer relaterade till organisation. Samtalen som telefonsjuksköterskorna tar emot är varierande till innehåll. Detta ställer krav på telefonsjuksköterskans professionella kompetens. Tidigare klinisk erfarenhet, bred kunskap och en god kommunikativ förmåga är viktiga egenskaper för telefonsjuksköterskan. Omvårdnadssituationen är komplex och för att kompensera för detta använder hon sig av olika strategier. Organisatoriska faktorer som påverkar triage och rådgivning via telefon är tillgången till beslutsstöd och tillgängligheten i vården. Framtida forskning som belyser hur telefonsjuksköterskan kan hantera stress och konfliktsituationer kan underlätta för telefonsjuksköterskan i hennes utsatta arbetssituation. Specialistutbildning till telefonsjuksköterska skulle göra vården säkrare för uppringaren men även förbereda telefonsjuksköterskan inför hennes yrkesroll.

<p>Telefonen har under de senaste årtiondena blivit ett viktigt redskap i hälso- och sjukvårdens arbete med människor som söker hjälp och råd för medicinska problem. Telefonlinjer till Sveriges vårdcentraler inrättades allmänt på 1970-talet. En betydande del av sjuksköterskornas arbete på vårdcentral består av telefonrådgivning. Den vårdsökande prioriteras och hänvisas till rätt vårdnivå utifrån den bedömning som görs vid dessa samtal. Syftet med studien är att få kunskap om vad sjuksköterskorna upplever när den vårdsökande inte kan beredas tid trots ett medicinskt behov, då läkartiderna inte räcker till på grund av brist på allmänläkare. Tio sjuksköterskor som arbetar med telefonrådgivning på vårdcentral intervjuades. Studien utfördes med en kvalitativ metod med fenomenologisk ansats. I resultatet framkommer att informanterna har flera olika känslomässiga upplevelser. Informanterna upplever att de inte alltid kan uppfylla det vårdgarantin lovar, men att problemet är organisationsrelaterat och ligger utanför deras egen kontroll. Telefonarbetet kan kännas betungande och tanken på hur det går för den vårdsökande finns ibland kvar efter arbetsdagens slut. Erfarenhet och kunskap anses viktigt för att bättre kunna hantera situationen och göra rätt bedömning. Det kollegiala stödet framhålls som betydelsefullt. Det anses viktigt att noggrant dokumentera givna råd och vilka åtgärder som planerats.</p> / <p>During the past decades the telephone has become an important tool in the healthcare system when people seek help and advice for medical problems. Telephone lines to all healthcare centres in Sweden were established in the 1970´s. A large part of nurses´ work at a healthcare centre consists of giving telephone advice. The callers´ medical needs are assessed and the callers are referred to the proper level of care. The aim of this study is to find out what nurses experience when the caller cannot be given an appointment, despite a medical need for one, because there are insufficient medical appointments available due to a shortage of general practitioners. Ten nurses working with telephone advice at healthcare centre were interviewed. The study was done with a qualitative method using a phenomenological approach. Results indicate that the informants have several different emotional experiences. The informants experience that they cannot always live up to the care guarantee, but that the problem is organizational and beyond their control. Sometimes telephone work feels heavy, and thoughts of how things go for the caller can continue when the work-day is finished. Experience and knowledge are considered important in order to be able to handle the situation better and to make a correct assessment. Support from colleagues is pointed out as meaningful. It is considered important to carefully document the advice given during the telephone call and which measures are planned.</p>

The purpose of this mixed methods study was to describe the cognitive processes/knowledge sources used by Emergency Department (ED) nurses in decision-making activities regarding triage and pediatric pain assessment and management. Deficiencies persist in ED pediatric pain assessment, and management methods or approaches that might help resolve these deficiencies have not been identified previously. Methodology triangulation with sequential use of qualitative- quantitative methods provided a rich description of knowledge sources and cognitive processes used by ED nurses relative to pediatric pain assessment decisions. Based on qualitative results, a set of vignettes was developed to assess ED nurses. Data analysis using ordinal logistic regression with a cumulative logit model identified patient and nurse variables which influence triage acuity decisions. Five common themes emerged from the qualitative data; 1) Age of the child is important, 2) Behavior can tell a lot, 3) Really looking at the patient, 4) Things that help make decisions, and 5) Things that hinder decisions. Ordinal logistic regression analysis of the quantitative data identified predictor variables of infants compared to school-age children, Hispanic ethnicity, moderate number of years of ED experience (11 -20 years) and years of education that were associated with higher triage levels .The implications of this new knowledge include changes in ED triage nurse practice towards pain assessment, and increased awareness of the need for education in use of pain assessment tools. Additional implications include education related to pain management practices by ED physicians and pain medication protocols at triage. This information may enhance triage and care of the pediatric patient experiencing pain, expand the knowledge base of emergency nursing, identify areas in which to implement changes, assist in improving care provided to children experiencing pain, and provide direction for future education, training, and research.

Thèse numérisée par la Division de la gestion de documents et des archives de l'Université de Montréal

SAMMANFATTNING I Sverige finns 70 sjukhusbundna akutmottagningar varav ett flertal utav dessa har en barnakutmottagning som har dygnsöppen verksamhet. Resterande sjukhus tar emot barn, men bemannas inte av specialiserade barnsjuksköterskor. Vanliga orsaker till att barn uppsöker en akutmottagning är i samband med skada, då de har feber, andningspåverkan eller vid problem med gastrointestinalkanalen. På ett flertal sjukhus används inte någon triageringsmodell för att bedöma barnet, vilket annars anses som en fördel eftersom barnet då bedöms utifrån liknande riktlinjer. Triagering används för att snabbt identifiera den patient som är svårast sjuk och därmed även i behov av snabbast vård och behandling. Patienten prioriteras utifrån fem olika nivåer. Få studier finns som beskriver sjuksköterskans upplevelser av att triagera barn. Därmed finns begränsad information om vilka faktorer som sjuksköterskan upplever påverkar triagen och om dessa inverkar positivt eller negativt på sjuksköterskans arbete. Syftet var att beskriva sjuksköterskors upplevelser av att triagera barn på barnakutmottagning. Sju intervjuer gjordes med sjuksköterskor på två olika barnakutmottagningar i södra Sverige. Intervjuerna var semi-strukturerade och utfördes från december 2014 till och med januari 2015. Som analysmetod användes kvalitativ innehållsanalys. Resultatet indikerar på att sjuksköterskan upplevde en lyckad triage då barnet kände sig tryggt och både triageringen och mätning av de vitala parametrarna då kunde utföras. Föräldrarnas medverkan upplevdes ha en stor del i om barnet kände sig tryggt med sjuksköterskan. Andningsfrekvensen var en vitalparameter som upplevdes svår att mäta. Då en hög arbetsbelastning inträffade upplevde sig sjuksköterskan stressad, vilket påverkade hur triagen utfördes. Triageringen upplevdes som en hjälp för sjuksköterskor med kortare erfarenhet. Sjuksköterskor med längre erfarenhet förlitade sig däremot i större utsträckning på den kliniska blicken. Triagen upplevdes som ett säkert system, både för patienten och för sjuksköterskan. Trygghet infann sig hos sjuksköterskan då barnet bedömdes utifrån samma kriterier och risken för felaktig bedömning ansågs då minskas. Barnets trygghet ger förutsättningar för en lyckad triage. Betydande faktorer tolkas vara stress och tidsbrist, vilket påverkar möjligheten att göra barnet tryggt. För sjuksköterskor med en kortare erfarenhet upplevs triageringen som fördelaktig, då deras beslut grundas på vedertagna riktlinjer. Triageringen tillför en säkerhetsaspekt för sjuksköterskan, såväl som för barnet.

The overall aim of this thesis was to investigate patient safety in the emergency department (ED) and to determine whether this varies according to patient safety culture, waiting, and outcomes of efficiency and quality variables. I: Patient safety culture was described in the EDs of two different hospitals before and after a quality improvement project. The questionnaire “Hospital Survey on Patient Safety Culture” was used to investigate the patient safety culture. The main finding was that the staff at both hospitals scored more positively in the dimension Team-work within hospital after implementing a new work model aimed at improving patient flow and patient safety in the ED. Otherwise, we found only modest improvements. II: Grounded theory was used to explore what happens in the ED from the staff perspective. Their main concern was reducing patients’ non-acceptable waiting time. Management of waiting was improved either by increasing the throughput of patient flow by structure pushing and by shuffling patients, or by changing the experience of waiting by calming patients and by feinting to cover up. III: Three Swedish EDs with different triage models were compared in terms of efficiency and quality. The median length of stay was 158 minutes for physician-led team triage compared with 243 and 197 minutes for nurse–emergency physician and nurse–junior physician triage, respectively. Quality indicators (i.e., patients leaving before treatment was completed, the rate of unscheduled return within 24 and 72 hours, and mortality rate within 7 and 30 days) improved under the physician-led team triage. IV: Efficiency and quality variables were compared from before (2008) to after (2012) a reorganization with a shift of triage model at a single ED. Time from registration to physician decreased by 47 minutes, and the length of stay decreased by 34 minutes. Several quality measures differed between the two years, in favour of 2012. Patients leaving before treatment was completed, unscheduled return within 24 and 72 hours, and mortality rate within 7 and 30 days all improved despite the reduced admission rate. In conclusion, the studies underscore the need to improve patient safety in the ED. It is important to the patient safety culture to reduce patient waiting because it dynamically affects both patients and staff. Physician-led team triage may be a suitable model for reducing patient waiting time and increasing patient safety.

Abstract The world is losing its biodiversity at an alarming rate and many agencies are committing to considerable investment in global conservation. Given the enormity of environmental issues, the funding available to managers is insufficient. Managers must make decisions about how to act within the bounds of this limited funding. Conservation decision-making is also limited by a lack of knowledge about the systems we are trying to conserve. Much of the information required for effective conservation is uncertain. In this thesis I focus on practical ways of approaching the immense predicament of how to make good conservation decisions in the face of these two limitations. In chapter two I provide both an optimal framework and analytic rule of thumb for allocating limited funding among subpopulations of a threatened species. My results show that the number of subpopulations we can effectively manage is driven by the economic constraints placed on management and the risk of extinction of the species we are trying to protect. We discover that it is rarely optimal to manage all the remaining isolated subpopulations of a threatened species. This highlights the importance of a triage approach to the management of subpopulations of a threatened species under the current climate of limited funding, leading us to coin the term ‘subpopulation triage’. One key area of uncertainty that links directly with how we allocate resources for conservation is uncertainty in the impact of our management actions on the systems we are trying to protect (the impact-investment curve). This relationship often drives the outcomes of our decision-making frameworks. In chapter three I investigate how uncertainty in the impact-investment curve, assumed in chapter two, alters our optimal management decision. Again, I find that limited conservation finances are a major limiting factor in the robustness of a strategy to our incomplete understanding. I discover that ‘subpopulation triage’ can be a natural consequence of robust decision-making. Uncertainty is not, however, always beyond our control. We can reduce it by diverting funding from management to collect data on our systems. This entails monitoring costs that must also be considered when making optimal conservation decisions. There are a number of reasons why we could monitor; to reduce our uncertainty in the status of threatened species where management is driven by species status; to aid learning about a component of the system we are managing; for both initial surveillance and adaptive approaches; and to report on the performances of conservation action to stakeholders. In chapter four I assess the benefit of initial surveillance to gain information on biodiversity value before we acquire a land parcel for the reserve network. The risk here is that the land parcel may be removed from the market during surveying. I describe both an optimal method, using stochastic dynamic programming (SDP), and a simple rule of thumb, for how to make such decisions. The solutions to this problem illustrate how optimal conservation is necessarily dynamic and that immediate implementation of a conservation plan may not always yield the best conservation outcome. Learning does not always need to take place in the absence of management. In chapter five I investigate adaptive learning for a threatened species where we must discriminate between multiple hypotheses of how the system works by implementing different management actions. We find that the optimal action depends on our belief in each model being the true model of our system, the benefit from each action under each model, and the number of sites available to implement an active adaptive strategy. In chapter six I investigate when one should learn about the state of the system through monitoring when management is state-dependent. Here our management of subpopulations of a threatened species is based on whether these subpopulations persist. I ask when should we survey or manage a subpopulation, and when, if ever, should we do nothing in a subpopulation of a threatened species. I find that management actions should not only be driven by the return on investment gained by managing a subpopulation but also by our certainty of the persistence of a subpopulation. This is the first work to show a direct trade-off between return on investment from conservation action and reduced uncertainty. One key evaluation method currently adopted worldwide is the use of ‘State of the Environment’ reporting. In chapter seven I assess the flaws of ‘State of the Environment’ reporting, the current method adopted worldwide for evaluating conservation policy. I show the positive biases inherent in such reporting and provide a new metric for reporting on conservation performance that is simple, transparent and provides an unbiased report on performance in reaching conservation objectives. I show that without honest reporting of conservation gains – and losses – we limit our ability to assess where we are in terms of conservation progress. Overall my thesis shows the need for managers to consider a triage approach to threatened species management, not as a process of giving up, but as a tool for ensuring species persistence in light of the urgency of most conservation requirements and the realities of financial and knowledge limitations. Indeed if conservation is a field dedicated to the protection of biodiversity then those responsible for decision-making––politicians, scientists and environmental managers––must use whatever approach gives the best outcome for the environment. Under current limitations, triage is often a necessity not an option.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2005. / Härtill 4 uppsatser.