Emergency medical care (EMC) is proposed by the World Health Organization (WHO) as being one of the core components of a horizontal approach to improving population health in low-resource settings; triage is considered to be a fundamental part of this field. Most studies exploring triage have focused on high-income countries. In 2004, the Cape Triage Group (CTG) developed the South African Triage Scale (SATS) a scale that uses a physiologically based scoring system together with a list of discriminators - designed to triage patients into one of four priority groups for medical attention. The SATS was designed for use in the South African context to mitigate the limited numbers of doctors and professional nurses. The SATS has been implemented and assessed extensively in South Africa, but its performance across a spectrum of different low-resource settings, particularly non-sub-Saharan African and trauma-only settings, has not been adequately assessed. Médecins Sans Frontières (MSF), an international humanitarian organisation, introduced EMC in 2006 into low-resource settings. In 2011, MSF began introducing the SATS in various projects where it was providing EMC. Methodology: This was a multi-site retrospective cohort study which sought to assess the reliability and validity of the SATS in different low-resource settings. Aim 1: To implement and evaluate the SATS in Northern Pakistan by describing the steps of implementation and how accurate nurses were in using the triage scale. After one month of implementation, 370 triage forms from a one-week period were evaluated. Aim 2: To assess the inter- and intra-rater reliability and accuracy of nurse triage ratings when using the SATS in an emergency centre (EC) in Timergara, Pakistan. Fifteen EC nurses assigned triage ratings to a set of 42 reference vignettes (written case reports of EC patients) under classroom conditions. Inter-rater reliability was assessed by comparing these triage ratings; intra-rater reliability was assessed by asking the nurses to re-triage ten 12 random vignettes from the original set of 42 vignettes and comparing the duplicate ratings. Accuracy of the nurse ratings was measured against the reference standard. Aim 3: To improve the ability to measure reliability and validity in paediatric settings by developing a set of paediatric paper-based vignettes using the Delphi methodology. In a two-round consensus building process, a panel of EC experts were asked to independently triage 50 clinical vignettes using one of four acuity levels: emergency (patient to be seen immediately), very urgent (patient to be seen within 10 min), urgent (patient to be seen within 60 min), or routine (patient to be seen within four hours). The vignettes were based on real paediatric EC cases in South Africa. Vignettes that reached a minimum of 80% group consensus for acuity ratings on either round one or two were included in the final set of reference vignettes. Aim 4: To further assess the reliability of the SATS across MSF-supported hospitals using paper-based vignettes in Afghanistan, Haiti and Sierra Leone. Applying the same methodology as in Northern Pakistan, we assessed reliability under classroom conditions between December 2013 and February 2014. Aim 5: To assess the validity of the SATS across MSF-supported hospitals between June 2013 and June 2014. Validity was assessed by comparing patients’ SATS ratings with their final EC outcomes (i.e., hospital admission, death or discharge) across four sites in Afghanistan, Haiti and Sierra Leone. Findings The SATS was able to be easily implemented and accurately completed in a low-resource setting of Northern Pakistan. We recommended further implementation and assessment of reliability and validity in low-resource settings. Across six sites with a total of 87 nurses, including two trauma-only hospitals in Afghanistan and Haiti, a paediatric-only hospital in Sierra Leone and three mixed medical settings in Afghanistan, Pakistan and Haiti, the SATS demonstrated moderate to substantial reliability. Across all settings in which we measured validity using outcome markers, SATS predicted an increase in the likelihood of admission/death when moving from low- to high-triage acuity. In trauma-only settings of Afghanistan and Haiti, the SATS showed a 1-9% under-triage and 13 a 2-16% over-triage rate. In mixed medical and paediatric settings, under-triage ranged from 0-76% while over-triage ranged from 2-88%. A more logical standardised approach to assessing validity was put forward when using outcome markers that would allow easier comparisons to be done across validity studies irrespective of the number of levels the triage scale had. We developed a set of paediatric vignettes for use in low-resource settings but cautioned against its use after measuring reliability using adult reference vignettes. We found that generic vignettes were poor substitutes in a variety of settings based on a lack of contextualisation and understanding by local nurses. Conclusion: The SATS has reasonable reliability with good validity across different ECs in various lower-source settings. The SATS is a valid triage tool for prioritisation of patients with trauma in low-resource settings. Its use in mixed EC settings seems justified, but in paediatric settings context-specific adjustments and assessments of its performance would be prudent.

Bakgrund: Triagering har en väsentlig roll vid bedömning av patienter på akutmottagningar. Triagerbedömningar görs genom att följa en triageskala enligt RETTS och utförs i de flesta fall av en sjuksköterska som är utbildad inom triage. Det finns olika triagesystem i olika delar av världen. En korrekt triagebedömning är grunden för tiden till att patienten får träffa en läkare på akutmottagningen.  Syfte: Syftet med studien är att undersöka och beskriva triagering på akutmottagningen, och eventuell betydelse för patientsäkerheten. Metod: För att besvara syftet valdes att genomföra en systematisk litteraturstudie. Sökningar gjordes i CINAHL och PubMed. Totalt elva kvantitativa artiklar inkluderades och data valdes ut med validerat undersökningsinstrument och mall för kvalitetsgranskning. Resultat: Resultatet delades in i tre huvudkategorier som täcker in artiklarnas innehåll. System och Nivåer, Faktorer vid triagering och Förmåga vid triagering. Slutsats: Studien visade på att triagering på akutmottagning påverkar patientsäkerheten. Klinisk erfarenhet av triagering, utbildning och följsamhet till triagesystem är viktiga faktorer för att kunna triagera korrekt. Patientsäkerheten är hotad vid felaktig triagering. / Background: Triage has a key role in assessing patients in the emergency departments. Triage assessment is done by following the triage scale RETTS and is conducted in most of the cases by a nurse who is educated within triage. There are several different triage systems in the world. A correct triage assessment is the base for how long a patient will wait before seeing a doctor in the emergency department.  Aim: The aim of the study was to investigate and describe triage assessment at emergency departments, and what that means for patient safety.    Method: To answer the purpose for the study a systematic literature study was chosen. Searches were carried out with the databases CINAHL and PubMed. A total of eleven quantitative studies were included. And data was selected with a validated search instrument and a template of quality review. Result: The result was sorted in three main categories that cover the contents of the articles. System and Level, Factors in triage and Ability in triage..  Conclusion: The Study showed that triaging in the emergency department affects patient safety. Clinic experience of triaging, education and adherence to the triage system are important factors to be able to correctly triage patients. Patient Safety is threatened when patients are wrongly triaged.

Patientflöden till Sveriges akutmottagningar ökar varje år. För att ta emot och bedöma pati­en­ter på ett patientsäkert sätt används triage. En välfungerande triageprocess är en förut­sätt­ning för ett patientsäkert arbete på akutmottagning. Syftet med denna studie var att göra en granskning av triageprocessen på akutmottagning, uti­från sjuksköterskors och läkares uppfattningar kring utbildning, förtroende och följsam­het.  Metoden var en deskriptiv tvärsnittsstudie baserad på en webbaserad enkätundersökning ställd till sjuksköterskor och läkare som arbetade inom triageprocessen på två sjukhus i Mel­lansverige. Inkluderade respondenter uppgick till n=191. Data har analyserats med hjälp av kvantitativ- och kvalitativ metod. Enkätfrågor med slutna svarsalternativ har analyserats kvantitativt med Chi-2-test [Χ2] och presenteras med deskriptiv statistik. Fritext­svar i enkä­ten har analyserats kvalitativt med manifest innehållsanalys.  Resultatet visar att det finns brister i triageutbildningen på akutmottagningarna som deltog i studien. Framförallt uppger läkarna att de saknar utbildning i triageverktyg och triagepro­cessens rutiner. Respondenternas svar visar att det finns brister i hur väl innehållet i utbild­ningen stämmer överens med hur arbetssättet tillämpas i den kliniska verksamheten och att respondenterna inte känner sig väl förberedda inför att börja arbeta med triage i klinisk verk­samhet. Patienternas sjukdomstillstånd anses inte identifieras adekvat av triageverktyg eller under triageprocess. Utifrån aspekter kring övertriagering samt identifiering av om­vårdnads­behov och medicinska behov har SATS högre förtroende hos sjuksköterskorna än DPT. Dock uppger respondenterna på båda akutmottagningarna att omvårdnadsbehov och medi­cinska behov inte fullt ut identifieras av triageverktyg eller under triageprocessen. Få respon­denter uppger att informationsöverföring i triageprocessen fungerar väl på deras ar­betsplat­ser. Det förekommer att respondenterna avviker från triageverktyget, triageproces­sens ruti­ner samt prioriteringsordning. Respondenternas uppfattningar är att läkare frångår oftare än sjuksköterskor. Sjuksköterskor som arbetar med sjuksköterskeledd triage anser i högre grad än övriga respondenter att bristande följsamhet till triageprocessens rutiner på­verkar patient­säkerheten på deras arbetsplats.  Slutsatsen är att det finns brister i triageprocessen på akutmottagningarna i studien som skulle kunna inverka negativt på patientsäkerheten. / Inflow of patients to Sweden’s emergency departments are increasing every year. In order to receive and assess patients in a patient-safe manner, triage is used. A well-functioning triage process is a prerequisite for patient-safe work at the emergency department. The aim of this review was to study the triage process in the emergency department based on nurses’ and physicians’ perceptions of education, confidence and compliance.  The method was a descriptive cross-sectional study, based on a web-based survey sent to nurses and physicians active in the triage process in two hospitals in Sweden. Respondents included amounted to n=191. Data have been analyzed using quantitative and qualitative meth­ods. Survey questions with closed answer options have been analyzed quantitatively with Chi-squared test [Χ2] and is presented using descriptive statistics. Free text replies have been analyzed qualitatively with manifest content analysis.  The results show that there are shortcomings concerning the triage education at the emer­gency departments participating in this study. Especially physicians state that they lack ed­ucation regarding the triage tool and in the triage process procedures. Respondents’ an­swers show that there are deficiencies regarding how well education content is consistent with how it is applied in the clini­cal ac­tivity and that respondents do not feel well prepared be­fore start­ing triage in clinical ac­tivities. Patients’ disease states are not regarded to be ad­e­quately identified by the triage tool or during the triage process. Based on aspects of over triage and identification of care and medical needs nurses show higher confidence in SATS than DPT. However, respondents at both emergency departments state that care and medi­cal needs are not fully identified by the triage tool or during the triage process. Few re­spondents state that infor­mation transfer in the triage process works well in their work­places. The re­spondents may deviate from the triage tool, the triage process procedures and priority order. Percep­tions of respondents are that physicians more frequently deviate than nurses. Nurses who work with nursing led triage consider in higher degree, than other re­spondents, that lack of compliance to triage process procedures affects patient safety at their place of work.  The conclusion is that there are shortcomings regarding the triage process in the emer­gency departments included in this study that could adversely affect patient safety.

Bakgrund: Sveriges akutmottagningar tog år 2022 emot 1 798 000 besök. För att prioritera patienters vårdbehov och därmed strukturera arbetet på akutmottagningen används triage. Triage utförs oftast av sjuksköterskor och är den initiala bedömningen av patienters medicinska allvarlighetsgrad. Syftet med triage är att de patienter med störst vårdbehov ska få företräde till vården. Triage är således av stor vikt för såväl patientsäkerheten som ett effektivt resursutnyttjande. Sjuksköterskors triagebedömningar beror på klinisk erfarenhet, intuition och andra kognitiva faktorer. Som teoretisk referensram användes Patricia Benners omvårdnadsteori ”från novis till expert”. Syfte: Att belysa sjuksköterskors erfarenheter av triage på akutmottagning. Metod: Studien genomfördes som en litteraturstudie med en kvalitativ och induktiv ansats. Datamaterialet utgjordes av 12 empiriska, vetenskapliga studier med kvalitativ ansats som analyserades enligt en trestegsmetod av Popenoe m.fl. Resultat: Tre teman samt sex subteman identifierades utifrån analys av datamaterialet; (1) Erfarenheter av triageprocessen, (2) Sjuksköterskors kompetens inom triage och (3) Arbetsmiljöns betydelse för triagearbetet. Konklusion: Sjuksköterskors triagearbete är beroende av många olika faktorer. Erfarenhet, färdigheter och utbildning underlättar arbetet med triage liksom att triagesystem, trots vissa brister, upplevs vara ett bra stöd för sjuksköterskor. Samverkan och miljön på akutmottagningen är i många avseenden utmanande då både bemanning och patientflöde har stor inverkan på triagearbetet. / Background: In 2022, emergency departments in Sweden received 1 798 000 patient visits. Triage is used to prioritize between patients' needs of care and to structure the work at the emergency department. Triage is usually performed by nurses and is the initial assessment of patients' medical acuity. The purpose of triage is that patients with the greatest acuity should be given priority for care. Thereby, triage is of great importance for both patient safety and an efficient use of resources. Nurses' triage assessments depend on clinical experience, intuition, and other cognitive factors. Patricia Benner's nursing theory "from novice to expert" was used as a theoretical frame of reference. Aim: To highlight nurses' experiences of triage in emergency departments. Method: The study was conducted as a literature review with a qualitative and inductive approach. The data material consisted of 12 empirical, scientific studies with a qualitative approach that were analyzed according to a three-step method by Popenoe et al. Results: Three themes and six sub themes were identified from the analysis of the data material; (1) Experiences of the triage process, (2) Nurses' competence in triage and (3) The impact of work environment in triage. Conclusion: Nurses' triage work is dependent on many different factors. Experience, skills, and education facilitate the work with triage. Triage systems, despite some shortcomings, are perceived to be a good support for the nurses. Collaboration and the environment at the emergency department are in many aspects challenging, as both staffing and patient flow have a major impact on the triage work.

La traumatologie est un problème de santé publique au troisième rang des années de vie perdues ajustées sur l’incapacité en France. L’investissement sanitaire et le volume de recherche qu’elle génère sont en deçà de ce que représente son impact sociétal. L’objet de ce travail de recherche était de plonger au cœur du parcours du patient traumatisé sévère pour en cibler trois problématiques clefs et tenter de répondre aux interrogations qu’elles génèrent.Les données utilisées provenaient essentiellement d’un observatoire de traumatologie lourde hospitalier (Traumabase®), régional et national, qui collige un ensemble de variables épidémiologiques, cliniques, paracliniques, et thérapeutiques des patients traumatisés sévères admis en centre de traumatologie.Le premier projet a ciblé l’orientation initiale (triage) des patients traumatisés sévères suite à un accident de la circulation au sein de la région Île de France et son effet sur la mortalité. Les patients initialement mal triés, transférés secondairement dans les centres de traumatologie régionaux, ne présentaient pas un pronostic plus sombre que les patients qui étaient transportés directement. Le système de soin dans son ensemble permettait de leur assurer un devenir équivalent. Une analyse en population réalisée par un chainage probabiliste des données avec les fiches d’accident de l’observatoire national de la sécurité routière a permis d’approcher le taux de sous triage conduisant au décès dans la région (0,15%) et d’objectiver que 60% des décès survenaient avant toute admission hospitalière.Le second projet visait l’optimisation de la jonction entre l’équipe médicalisée préhospitalière et l’équipe intrahospitalière. Il s’est attelé à développer un outil de prédiction de la sévérité des patients hémorragiques pour permettre l’anticipation de l’admission des patients les plus graves. Cet outil, le Red Flag, avait pour cahier des charges d’être simple et pragmatique, et de ne pas nécessiter de dispositif externe pour l’utiliser. Il a identifié cinq caractéristiques (shock index>1, pression artérielle moyenne <70mmHg, hémoglobine capillaire < 13g/dL, bassin instable et intubation), dont la présence de deux ou plus d’entre-elles permettait d’activer l’alerte pour l’hôpital receveur. Cet outil devra être évalué en prospectif pour confirmer ses performances et évaluer son impact sur l’organisation et le devenir des patients.Le troisième projet de recherche ciblait plus spécifiquement une des thérapeutiques de la coagulopathie aigue du traumatisé sévère en choc hémorragique. Il a tenté de quantifier l’impact de l’administration de concentré de fibrinogène à la phase précoce du choc hémorragique traumatique (6 premières heures) sur la mortalité toutes causes confondues des 24 premières heures par une approche d’inférence causale (score de propension et méthode d’estimation double robuste). Il n’a pas été retrouvé d’effet significatif sur la mortalité, un manque de puissance pouvant être responsable de ce résultat (différence de risque observée : -0,031, Intervalle de confiance 95% [-0,084 ; 0,021]).Ainsi l’ensemble de ces 3 projets de recherche ont permis de répondre à des problématiques ciblées du parcours du patient traumatisé sévère, générant par la même de nouvelles perspectives d’analyse pour mieux circonscrire les réponses de terrain. / In France, the third most frequent cause of disability adjusted life years lost is trauma, an observation that makes trauma a public health challenge. However, investment in trauma care and specific research fails to meet this challenge and to acknowledge the associated societal and economic impact.The purpose of this research was to explore the core of the pathway of a major trauma patient and bring to light key issues and question and to find answers. The data used in this research were mainly extracted from a regional and national trauma registry, the Traumabase®. The registry collects epidemiological, clinical, paraclinical and therapeutic variables for patients with severe trauma admitted to participating trauma centres. The first project focused on the effects of triage on patients with severe trauma following a road traffic accident in the Ile de France region. Patients who were initially under triaged and then transferred to regional trauma centres did not have a worse prognosis than patients who were transported directly. The emergency medical system as a whole ensured that they would have an equivalent outcome. A population analysis carried out by a probabilistic data chainage using the accident records of the National Road Safety Observatory made it possible to approach the undertriage rate leading to death in the region (0.15%) and to reveal that 60% of deaths occurred before any hospital admission. The second project developed a pragmatic pre-alert tool based on simple, clinical prehospital criteria to predict acute hemorrhage in trauma patients. This tool is meant to increase the performance of the receiving hospital trauma team of these critically sick patients and activate a specific hemorrhage pathway. The study identified five variables (shock index>1, mean blood pressure <70mmHg, capillary hemoglobin <13g/dL, unstable pelvis and intubation). If two or more variables were present, the tool identified patient with acute hemorrhage and the corresponding pathway should be activated. This tool requires prospective validation and assessment of its impact on care provision and patient outcome.The third research project focused on a therapeutic component of trauma induced coagulopathy. The study attempted to quantify the effect of fibrinogen concentrate administration at the early phase of traumatic hemorrhagic shock (first 6 hours) on 24 hours all-cause mortality using a causal inference approach (propensity score and double robust estimator). The research did not demonstrate any impact on mortality (observed risk difference: -0.031, 95% confidence interval [-0.084; 0.021]);  a lack of power might be responsible for this result.

Aims: To describe the presence of trauma team activation and outcomes of health care interventions in two trauma team levels. Background: Trauma is the most common cause of death among Swedish men aged &lt;44 years. Every year ca 4500 people in Sweden dies due to trauma. During the 90’s, hospitals in USA developed a two level trauma activation algorithm to speed up the initial assessment for the injured patients who needed it, and to conserve resources when patients didn’t need to see the full trauma team. Design: This study is a retrospective records audit over trauma team activations during 2 years. Methods: This study audited trauma team activations through medical records during the period 1/1 2013 - 31/12 2014 on Norrlands university hospital in Umeå, Sweden. Results: Of all the trauma team activations 35% activated the large trauma team and 65% the small trauma team. Average age was 44 years and 61% of the patients were men while 39% were women. 36,3% of the large trauma team activations were in need of anaesthesiological interventions and 1% of the small trauma team activations. 47,8% was in need of Intensive care of the large trauma team activation and 3,5% of the small trauma team activation. 41,6% of the large trauma team activation was planned for surgery within the first 24-hours and 4,5 of the small. Mean wardtime was 8,49 days for the large trauma team activation and 2,86 days for small trauma team activation. Mortality for large trauma team activation was 8,8% compared to 1,5 of the small. Conclusion: This study shows that two levels of trauma team activation can provide a safe and appropriate care. More longitudinal and multicenter studies is necessary for increased evidence. / Syfte: Att beskriva förekomst av aktiverade traumalarm samt utfall av vårdinsatser i två traumalarmsnivåer. Bakgrund: Trauma är den vanligaste dödsorsaken bland män under 44år i Sverige, totalt avlider ca 4500 personer per år till följd av trauma. I USA infördes under 90-talet två traumalarmsnivåer för att öka patientsäkerheten och spara vårdresurser. Design: Denna studie är en retrospektiv journalgranskning över traumalarm som inträffat under en 2 års period. Metod: Studien granskade aktiverade traumalarm via journaldata från perioden 1/1-2013 t.o.m 31/12-2014 på Norrlands Universitetssjukhus i Umeå. Resultat: Av de aktiverade traumalarmen var 35% stora och 65% små. Medelåldern var 44år och 61% av patienterna var män medan 39% var kvinnor. 36,3% av de stora traumalarmen var i behov av narkoskompetens och 1% av de små. 47,8% av de stora traumalarmen var i behov av IVA-vård samt 3,5% av de små. 41,6% av stora traumalarm planerades för operation inom 24timmar och 4,5% av de små. Medelvårdtiden var 8,49 dygn för stora traumalarm och 2,86 dygn för små traumalarm. Mortaliteten för stort traumalarm var 8,8% jämfört med 1,5% av de små traumalarmen. Slutsats: Denna studie visar på att triagering enligt två traumalarmsnivåer för vuxna kan i hög grad ge en patientsäker och ändamålsenlig vård. Fler longitudinella och multicenterstudier i området är nödvändigt för ökad evidens

Bakgrund: En specialistutbildad ambulanssjuksköterska ska enligt kompetensbeskrivningen kunna bedöma och prioritera en patient till rätt vårdnivå. Är patienten inte i behov av ambulanstransport eller patienten själv beslutar att han/hon inte vill medfölja ambulansen lämnas patienten kvar på plats med eventuell hänvisning till annan vårdnivå.   Syfte: Syftet var att studera ambulanssjuksköterskans erfarenheter i samband med att patienten inte medföljer ambulansen efter en prehospital bedömning.   Metod: Ett frågeformulär med öppna svarsalternativ användes bland ambulanssjuksköterskorna inom Landstinget Blekinge. Analysen av svaren gjordes med kvalitativ innehållsanalys enligt Granheim och Lundman (2004).   Resultat: Utifrån data som insamlades formulerades ett övergripande tema: Att fungera som grindvakt med behov av stöd och förankring i sina beslut. Ambulanssjuksköterskorna upplevde det som en viktig men svår uppgift att kvarlämna patienten om ambulanstransport inte behövdes. Vid tveksamma bedömningsfall eller när patienten inte vill medfölja i ambulans trots bedömt behov, upplevde ambulanssjuksköterskan en oro för eventuella konsekvenser av att lämna patient kvar på plats. Befogenheten att kunna kvarlämna patienten efter en prehospital bedömning upplevdes öka tillgängligheten för patienter med störst behov av ambulanssjukvård och ambulanstransport. Ambulanssjuksköterskorna upplevde ett behov av stöd, särskilt av bättre läkarstöd i sin bedömning.   Slutsats: Det ökade antalet ambulansuppdrag i Blekinge och Sverige i övrigt ställer höga krav på ett mer effektivt och befogat utnyttjande av de begränsade ambulansresurser som existerar.  Föreliggande studie visar på ambulanssjuksköterskans erfarenhet av ett behov av stöd från läkare som är insatta i ambulansens förutsättningar och arbetsmetoder. Detta behövs för att minska ambulanssjuksköterskornas upplevda osäkerhet när beslut om ambulanstransportbehov tas.

Early closure to functional correctness of the final chip has become a crucial success factor in the semiconductor industry. In this context, the tedious task of functional debugging poses a significant bottleneck in modern electronic design processes, where new problems related to debugging are constantly introduced and predominantly performed manually. This dissertation proposes methodologies that address two emerging debugging problems in modern design flows. First, it proposes a novel and automated triage framework for Register-Transfer-Level (RTL) debugging. The proposed framework employs clustering techniques to automate the grouping of a plethora of failures that occur during regression verification. Experiments demonstrate accuracy improvements of up to 40% compared to existing triage methodologies. Next, it introduces new techniques for Field Programmable Gate Array (FPGA) debugging that leverage reconfigurability to allow debugging to operate without iterative executions of computationally-intensive design re-synthesis tools. Experiments demonstrate productivity improvements of up to 30 x vs. conventional approaches.

Abstrakt Bakgrund: Telefonrådgivning har blivit en alltmer vanlig arbetsuppgift för sjuksköterskor som arbetar på hälsocentral inom primärvården. Det är ett sätt för uppringeren att komma i kontakt med hälso- och sjukvården. Telefonrådgivning innebär att telefonsjuksköterskan gör en snabb bedömning av uppringarens tillstånd  och hänvisar uppringaren till lämplig vårdnivå men även ger råd, stöd och undervisning. Kommunikationen har central betydelse där telefonsjuksköterskan måste kunna tolka även icke-verbal kommunikation. Telefonsjuksköterskan måste anpassa sitt arbete och sina beslut efter vetenskapliga, organisatoriska , ekonomiska och tekniska aspekter. Syfte: Att belysa telefonsjuksköterskans erfarenhet av att arbeta med telefonrådgivning. Metod: En litteraturöversikt baserad på åtta  artiklar som inkluderades efter kvalitetsgranskning. Resultatet sammanställdes utifrån en integrerad analys. Resultat: I analysen identifierades fyra huvudkategorier; möte med uppringaren, att göra bedömningar och ta beslut , ökande kravbild, samt känslor för arbetet, vilka  utmynnade i 7 underkategorier.  Faktorer som identifierades var att inte se uppringaren när man kommunicerar och tolkar både de verbala och icke visuella signalerna och att samtidigt vara både dörrvakt  och vårda uppringarna. Att rätt frågor ställs för att göra rätt bedömning betonas. Arbetet upplevs stimulerande men även stressande för telefonsjuksköterskor. Slutsats: Telefonrådgivning är en utmanande och stimulerande men svår arbetsuppgift. Att kunna sortera och förstå problemen utan att se uppringaren och samtidigt ställas inför de etiska svårigheter som genus och etnicitet gör att det ställs stora krav på telefonsjuksköterskan.

Background and objectives There has been a steady annual increase in the number of deliveries performed at Chris Hani Baragwanath Hospital in recent years. A 2004 audit found that approximately one third of deliveries conducted at the hospital were of women who had referred themselves and were low risk and as such did not require delivery at a specialist centre. A triage down-referral system back to midwife obstetric units was implemented in 2008 to address the problem of low-risk self-referrals at the hospital. This study was conducted after the establishment of the triage system to find out whether the establishment of the triage system had been accompanied by a decrease in the proportion of self-referred women presenting to Chris Hani Baragwanath Hospital in labour, and to assess delivery outcomes in these patients. Literature review The literature review was conducted using Pubmed and MDConsult using the key words self referral, triage, gatekeeper, low-risk pregnancy, maternity / labour and referral systems. Relevant references were accessed via the University of the Witwatersrand eJournal portal. Appropriate articles cited by other authors were also reviewed. Appropriate websites were also used and referenced. Methods This was a retrospective descriptive study which included all women presenting in labour to the hospital maternity admissions area. The study population was clinical case-files of all births that were admitted in labour from 1 May to 31 May 2010. A simple random sample of these files was drawn. Results One hundred and eighty two intra-partum admissions were sampled. Thirty-five (19%) of these women were self-referred. Seven out of the 35 (20%) required caesarean sections. Five more (14%) needed oxytocin augmentation of labour, and one more (3%) had a vacuum delivery. Twenty women (57%) did not develop any complications during labour and could have been delivered at their midwife obstetrics units. During the month of the study, the triage down-referral system attended to 171 women and down-referred 83 (49%). Conclusion The establishment of a triage down- referral system has been accompanied by a curtailment in the number of low-risk pregnancies presenting self-referred at the referral hospital labour ward, compared with the audit in 2004.