<p>Syftet var att genom journalgranskning kartlägga i vilken omfattning identifiering och dokumentation görs av förekomsten av avoidable factors hos skallskadade patienter, av sjuksköterskor på en neurointensivvårdsavdelning (NIVA), samt undersöka överensstämmelsen mellan dokumentation och monitorvärden rörande intrakraniellt tryck (ICP), cerebralt perfusionstryck (CPP), systoliskt blodtryck (SBT) och temperatur som registrerats via övervakningsutrustningen. Dokumentationen gjordes med ledning av en befintlig guideline. Urvalet var konsekutivt och studien innefattade 25 patienter. Antalet bedömningar i studien var totalt 2176 stycken. Vid 85 % av bedömningstillfällena dokumenterade sjuksköterskan i bedömningsformuläret. För ICP, CPP och SBT bedömdes det vid 70-80 % av tillfällena som att inga problem hade funnits och vid 55 % av tillfällena bedömdes det att det inte varit några problem med temperaturen. Det fanns signifikanta skillnader mellan då avvikelser och inga avvikelser var dokumenterade för insulttiden för ICP, samt insulttiden och monitormedelvärde för CPP och temperatur. Med hjälp av guidelines och formulär för att dokumentera avoidable factors kan patienter med sekundära insulter identifieras i stor utsträckning. Insulttiden då värdena avviker från det normala väger in starkare i bedömningen än hur avvikande värdet varit.</p><p>Att vårda skallskadade patienter innebär att<strong> </strong>ständigt väga behovet av omvårdnadsåtgärder mot risken för att det kan leda till sekundära insulter.</p><p> </p>

Syftet var att genom journalgranskning kartlägga i vilken omfattning identifiering och dokumentation görs av förekomsten av avoidable factors hos skallskadade patienter, av sjuksköterskor på en neurointensivvårdsavdelning (NIVA), samt undersöka överensstämmelsen mellan dokumentation och monitorvärden rörande intrakraniellt tryck (ICP), cerebralt perfusionstryck (CPP), systoliskt blodtryck (SBT) och temperatur som registrerats via övervakningsutrustningen. Dokumentationen gjordes med ledning av en befintlig guideline. Urvalet var konsekutivt och studien innefattade 25 patienter. Antalet bedömningar i studien var totalt 2176 stycken. Vid 85 % av bedömningstillfällena dokumenterade sjuksköterskan i bedömningsformuläret. För ICP, CPP och SBT bedömdes det vid 70-80 % av tillfällena som att inga problem hade funnits och vid 55 % av tillfällena bedömdes det att det inte varit några problem med temperaturen. Det fanns signifikanta skillnader mellan då avvikelser och inga avvikelser var dokumenterade för insulttiden för ICP, samt insulttiden och monitormedelvärde för CPP och temperatur. Med hjälp av guidelines och formulär för att dokumentera avoidable factors kan patienter med sekundära insulter identifieras i stor utsträckning. Insulttiden då värdena avviker från det normala väger in starkare i bedömningen än hur avvikande värdet varit. Att vårda skallskadade patienter innebär att ständigt väga behovet av omvårdnadsåtgärder mot risken för att det kan leda till sekundära insulter.

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PhD Thesis / Background: Overcrowding in emergency departments (EDs) due to avoidable visits places a significant strain on health systems. There is no known valid classification to identify avoidable ED visits in Canadian administrative data. Research Questions: Which physician interventions and patient characteristics are important to classify avoidable ED visits, and does a novel classification (the Emergency Department Avoidability Classification; EDAC), which incorporated these features, demonstrate validity? Methods: Two independent modified Delphi consensus studies determined ED physician interventions and patient characteristics that classified avoidable ED visits. These studies involved emergency and family medicine physicians across Ontario, Canada. Binary logistic regression was used to examine ED physician interventions in the National Ambulatory Care Reporting System (NACRS) database for associations with patient characteristics. These results constructed the EDAC criteria. ED physicians from an academic hospital evaluated randomly selected retrospective ED visits (n=320) which were also evaluated using the EDAC to assess their avoidability. The primary outcome of this thesis was correlation between the classification and ED physician judgements, measured using a Spearman rank correlation and ordinal logistic regression. The secondary outcome was to compare the correlations of previously published classifications with ED physician judgements. The tertiary outcome was to compare prevalence estimates of avoidable ED visits for all classifications. Results: Consensus showed strong evidence on 146 of 150 (97.3%) ED physician interventions, with 103 (68.7%) deemed suitable for non-ED care. Consensus was established on eight of nine patient characteristics, with four characteristics identified as useful in specifying avoidable ED visits: age (18-70 years), triage acuity (non-emergent), specialist consult in the ED (none) and ED visit outcome (discharged). An adjusted retrospective cohort study found the ED interventions had a strong association with patient characteristics determined in the consensus study: not aged over 65 years, having a non-emergent triage acuity and not being admitted to hospital. The classification was highly correlated with ED physician judgements (r=0.64, p<0.01), with a significant association to classify avoidable ED visits (OR=80.0, 95% CI=17.1-374.9) and strong accuracy (82.8%). The EDAC was the most accurate classifier of avoidable ED visits compared to previously published classifications. The EDAC identified a prevalence of 25.1% ED visits as avoidable and common patient conditions associated with such visits as traumatic injuries, symptoms/signs/abnormal findings, diseases of the musculoskeletal system, mental and behavioural disorders, and diseases of the respiratory system. Conclusion: My thesis developed and established the EDAC as an accurate classifier of avoidable ED visits with supporting evidence of validity and superior performance to previously published classifications. The EDAC can be easily integrated with administrative ED data and has strong potential for use in defining avoidable ED visits by health policy stakeholders. / Thesis / Doctor of Philosophy (PhD)

This thesis consists of the four papers listed below and a survey of the research area. I Lina J. Andrén: Avoiding (m, m, m)-arrays of order n = 2k II Lina J. Andrén: Avoidability of random arrays III Lina J. Andr´en: Avoidability by Latin squares of arrays with even order IV Lina J. Andrén, Carl Johan Casselgren and Lars-Daniel Öhman: Avoiding arrays of odd order by Latin squares Papers I, III and IV are all concerned with a conjecture by Häggkvist saying that there is a constant c such that for any positive integer n, if m ≤ cn, then for every n × n array A of subsets of {1, . . . , n} such that no cell contains a set of size greater than m, and none of the elements 1, . . . , n belongs to more than m of the sets in any row or any column of A, there is a Latin square L on the symbols 1, . . . , n such that there is no cell in L that contains a symbol that belongs to the set in the corresponding cell of A. Such a Latin square is said to avoid A. In Paper I, the conjecture is proved in the special case of order n = 2k . Paper III improves on the techniques of Paper I, expanding the proof to cover all arrays of even order. Finally, in Paper IV, similar methods are used together with a recoloring theorem to prove the conjecture for all orders. Paper II considers another aspect of the problem by asking to what extent way a deterministic result concerning the existence of Latin squares that avoid certain arrays can be used when the sets in the array are assigned randomly. / Denna avhandling inehåller de fyra nedan uppräknade artiklarna, samt en översikt av forskningsområdet. I Lina J. Andrén: Avoiding (m, m, m)-arrays of order n = 2k II Lina J. Andrén: Avoidability of random arrays III Lina J. Andrén: Avoidability by Latin squares of arrays with even order IV Lina J. Andrén, Carl Johan Casselgren and Lars-Daniel Öhman: Avoiding arrays of odd order by Latin squares Artikel I, III och IV behandlar en förmodan av Häggkvist, som säger att det finns en konstant c sådan att för varje positivt heltal n gäller att om m ≤ cn så finns för varje n × n array A av delmängder till {1, . . . ,n} sådan att ingen cell i A i innehåller fler än m symboler, och ingen symbol förekommer i fler än m celler i någon av raderna eller kolumnerna, så finns en latinsk kvadrat L sådan att ingen cell i L innehåller en symbol som förekommer i motsvarande cell i A. En sådan latinsk kvadrat sägs undvika A. Artikel I innehåller ett bevis av förmodan i specialfallet n = 2k. Artikel III använder och utökar metoderna i Artikel I till ett bevis av förmodan för alla latinska kvadrater av jämn ordning. Förmodan visas slutligen för samtliga ordningar i Artikel IV, där bevismetoden liknar den som finns i i Artikel I och III tillsammans med en omfärgningssats. Artikel II behandlar en annan aspekt av problemet genom att undersöka vad ett deterministiskt resultat om existens av latinska kvadrater som undviker en viss typ av array säger om arrayer där mängderna tilldelas slumpmässigt.

Background: Hospitalizations for pediatric gastroenteritis are considered potentially avoidable and are used to monitor access and quality of primary care for children. Previous reports have found pediatric gastroenteritis admissions higher in Florida compared to the South and the nation.Purpose: The purpose of this project was to explore variation in county admission rates for pediatric gastroenteritis related to non-clinical factors in Florida during 1995-2002. Specific aims included identifying the unique contributions of county socioeconomic characteristics and availability of primary care resources to annual county pediatric gastroenteritis hospital admission rates. Method: The study was retrospective and longitudinal assessing variation in annual county admission rates for pediatric gastroenteritis from 1995 to 2002. Secondary data sources included Florida hospital discharge data and multiple publicly available state and federal datasets. Explanatory variables included county-level measures of socioeconomic status and primary healthcare resources. Analysis: Multivariate analysis was performed using multilevel modeling techniques. A two-level, random coefficients model was constructed in HLM6 to account for variation over years and across counties. Linear and non-linear trends over time were also assessed. Results: None of the hypotheses were supported by the data. The average pediatric gastroenteritis admission rate across all occasions and counties was 205.72 admissions per 100,000 child population. The proportion of children 0-4 years was the only significant predictor of pediatric gastroenteritis rates. Conclusion/Discussion: The significant effect of age on admission rate was not surprising and was well supported in the literature. Missing data issues and low statistical power may have contributed to the lack of significant effects of other explanatory variables

In 1999, the Institute of Medicine estimated as many as 98,000 patients died each year in US hospitals as the result of medical errors. Five years later, another report estimated 195,000 people died unnecessarily. A recent study of patient safety in American hospitals concluded that 87% of Medicare deaths identified over a three-year period were "potentially preventable." The rapid response team (RRT) has been recommended as an effective strategy for reducing avoidable patient deaths as measured by patient safety indicator #4 (PSI#4), Death among surgical inpatients with treatable serious complications [formerly failure to rescue]. There is no research evidence to support the recommendation. The purpose of this exploratory research study was to describe RRT characteristics, determine RRT penetration, and measure PSI#4 (Death among surgical inpatients) rates among hospitals in a large metropolitan area hospital council. A retrospective, descriptive design was used during analysis of survey data collected from members of the hospital council and secondary analysis of administrative data submitted by the same hospitals to a regional data warehouse. All of the hospitals represented by survey submissions had implemented RRTs. The majority of teams was nurse-led and could be activated by a wide range of hospital staff and family members. The hospitals used evidence-based criteria for RRT activation. There was a downward trend in the regional PSI#4 rate from 2003 to 2008, which was not statistically significant, but may be considered clinically significant. Nurse administrators viewed RRTs as effectively supporting nursing care. This study provided a first look at RRTs in relation to an untested patient safety indicator that measured avoidable patient deaths. More research with a larger sample size with adequate power to support statistical analysis of differences in PSI #4 rates over time will provide evidence regarding relationships among hospital characteristics, RRT characteristics, and avoidable deaths among surgical inpatients. / text

Magister Curationis - MCur / Background: The neonatal period starts at birth and ends 28 days after birth, and is the most defence less period in the newborn's life. Improving newborn health is a priority for the Ministry of Health and Social Services (MoHSS) in Namibia. The national neonatal mortality rate stood at 21.80 per 1000 live births in the country, and Namibia was unable to attain Millennium Development Goal 4 which focused on reduction of the child mortality rate by two-thirds between 1990 and 2015. Aim: This study investigated the factors contributing to neonatal deaths at a national hospital in the Khomas region of Namibia, with the following objectives: (i) to identify causes of early neonatal deaths; (ii) to identify the causes of late neonatal deaths; and (iii) to identify avoidable and unavoidable factors contributing to neonatal deaths. Methodology: The study used a quantitative research approach with a retrospective descriptive design to investigate factors contributing to neonatal deaths. The primary data were collected from a population of 231 record files of all neonates who died during the period 1 January to 31 December 2013 while admitted to the national hospital before 28 completed days of life. Results: The study identified that of the neonates who died, 67.1% (n=155) were early neonatal deaths (during the first 0–7 days of life), while 32.9% (n=76) died during the late neonatal period (from 8–28 days of life). Of the neonates who died, 50.6% (n=117) were male and 48.48% (n=112) were female. The causes of early and late neonatal deaths were similar, although they happened at different stages. The causes of early neonatal deaths have been identified as respiratory distress syndrome (RDS) – 24.2% (n=56); neonatal sepsis – 12.1% (n=28); birth asphyxia – 11.7 % (n=27); congenital abnormalities – 14.7 % (n=34); hemorrhagic diseases of newborns – 3.9% (n=9); and unknown – 0.6% (n=1). Neonatal sepsis caused the highest number of late neonatal deaths 17.7 %,( n=41); followed by RDS – 7.4% (n=17); congenital abnormalities – 3.9% (n=9); birth asphyxia – 3.1% (n=7); birth trauma – 0.4% (n=1); and unknown factors – 0.4 % (n=1). The study revealed that avoidable factors related to healthcare providers had a severe impact on neonatal deaths, while congenital abnormalities were unavoidable factors. Conclusion: The study concluded that most neonatal deaths are related to actions or inactions of the healthcare providers and could be avoided. Recommendations: Based on the results of the study, further research is required to assess the knowledge, skills, and behaviors of the healthcare providers. Training and education about neonatal resuscitation needs to be carried out on a regular basis.

La progression de l’espérance de vie au Québec reflète l’amélioration de la santé de la population. Toutefois, des décès continuent à survenir prématurément avant l’âge de 75 ans. Une part de cette mortalité prématurée est potentiellement évitable. L'objectif de ce mémoire est d’estimer la mortalité évitable au Québec de 1981-1985 à 2005-2009. Pour cela, la méthode de Tobias et Jackson (2001) a été appliquée sur des données de décès, fournies par l’Institut national de santé publique du Québec, pour estimer les taux de mortalité évitable totale et pour chacun des sexes. Cette approche nous a, par ailleurs, permis d’estimer des taux de mortalité évitable selon trois paliers de prévention : primaire, secondaire et tertiaire. Nos résultats démontrent une tendance à la baisse de la mortalité évitable à travers le temps. Cette baisse a été enregistrée chez les deux sexes, mais des disparités de mortalité évitable existent entre les hommes et les femmes. En effet, la mortalité évitable des hommes est plus élevée que celle des femmes et cet écart de mortalité est principalement dû à la mortalité évitable associée à la prévention primaire. L’analyse de la mortalité évitable par cause de décès fait ressortir que le cancer du poumon est la principale cause de décès évitable tant chez les hommes que chez les femmes en 2005-2009. Durant cette même période, le cancer du sein et les cardiopathies ischémiques étaient la deuxième cause de décès évitable respectivement chez les femmes et chez les hommes. / The upward trend observed in Quebec’s life expectancy in past years suggests that population health has continued to improve. However, a number of deaths continue to occur prematurely before the age of 75 years. A part of this premature mortality is potentially avoidable. The objective of this paper is to estimate avoidable mortality rates in Quebec from 1981-1985 to 2005-2009. Avoidable mortality rates were obtained by applying the method of Tobias and Jackson (2001) to mortality data made available to us by the Institut national de santé publique du Québec. Furthermore, this approach allowed us to evaluate avoidable mortality rates by three levels of prevention: primary, secondary and tertiary. Our results show a downward trend in avoidable mortality from 1981-1985 to 2005-2009. This decline was observed for the whole population and also for both sexes. Differences in male’s and female’s avoidable mortality trends are however noticed. Indeed, avoidable mortality is higher for men than women and a large part of this difference is associated to primary prevention. The analysis by cause of death revealed that lung cancer was the leading cause of avoidable death in both men and women in 2005-2009. During this same period, the second leading cause of avoidable mortality is breast cancer and ischemic heart diseases in females and males respectively.

Pressure ulcers (PUs) present intrinsic risk factors that are not consistently identified by clinical assessments. The objective of this project was to develop a clinical practice guideline (CPG) to provide nurses with guidance in identifying and differentiating how intrinsic and extrinsic risk factors are associated with populations at risk for developing avoidable and unavoidable PUs. CPG development followed a systematic method to search the literature, organize findings, and assess the strength of the resulting evidence and its applicability to the CPG. Quality of the CPG was assessed by a panel of 8 health care professionals using the Appraisal of Guidelines for Research & Evaluation II instrument. Findings of the assessment indicated a high overall quality of the CPG; its immediate use was recommended and systematic evaluation was suggested to promote usage in a wider array of health care contexts. The quality domains with the highest scores were scope, purpose, applicability, editorial independence (all 100%), rigor of development (99.7%), and clarity of presentation (99.3%). The stakeholder involvement domain demonstrated the lowest--yet still robust--score (94.4%). The CPG can be used to emphasize appropriate and specific nursing competencies for making informed decisions when identifying and describing patients at risk for developing PUs. Further research and evaluation of the use of this CPG will be useful to demonstrate how CPGs can help to decrease the incidence of avoidable PUs. The potential for positive social change relative to the prevention of PUs is high. Decreased incidence of preventable PUs will eliminate unnecessary health care costs and improve overall health outcomes of patients at all levels of socioeconomic status.