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Chest pain is a common presenting complaint to emergency departments (EDs) and is a symptom of serious cardiovascular events such as myocardial infarction (MI) and possibly cardiovascular death. Early decision-making regarding patient disposition is crucial for early intervention and to avoid ED congestion. The Third Universal Definition of MI states that MI diagnosis be made using electrocardiogram (ECG) findings and/or a rise and/or fall in cardiac troponin (cTn) concentrations. However, patients with ECG abnormalities represent less than 1/3 of all ACS patients, leaving the remaining to be diagnosed using multiple measurements of cTn over several hours. I therefore aimed to develop a strategy to identify patients at low-risk for major adverse cardiovascular events (early rule-out), as well as those at greatest short-term cardiac risk (early rule-in). In this thesis I present published work on the clinical utility of glycogen phosphorylase Isoenzyme BB (metabolic marker) in combination with high-sensitivity cTn (hs-cTn) to rule-out adverse cardiac events within 72hrs for patients presenting to the ED within 6hrs of ACS symptom onset. I further assessed the utility of metabolic markers using glucose in this setting. Preliminary results show that using a “healthy” hs-cTn concentration with a normal glucose measurement at presentation can be used to rule-out patients who present to the ED with clinical suspicion of ischemia. Further expansion of this hypothesis demonstrated that an algorithm incorporating both glucose and cTn can effectively rule-in/rule-out MI or MI/cardiovascular death in patients who present to the ED with symptoms of ACS. In addition, presentation hemoglobin A1c identified previously unknown diabetes; which may have overall health implications for these patients. I also demonstrate that using glucose in combination with cTn is a cost-effective decision-making tool in the ED as compared to cTn alone. Application of these rule-in/rule-out algorithms can improve morbidity/mortality rates, and alleviate healthcare burdens. / Thesis / Doctor of Philosophy (Medical Science) / Myocardial ischemia is a reduction in coronary blood flow that is insufficient for heart cell demand, which can lead to myocardial injury and cell death. Acute Coronary Syndrome (ACS) encompasses three clinical presentations of myocardial ischemia: ST-elevation MI (STEMI), non-STEMI (NSTEMI) and unstable angina (UA). Current guidelines recommend using electrocardiogram (ECG) findings and multiple cardiac troponin (cTn) measurements over several hours to diagnose (rule-in) or rule-out ACS in the emergency department (ED). However, given these recommendations patients may spend several hours in the ED, consuming valuable time and resources. This project explores the use of glycemic biomarkers [e.g., glucose and haemoglobin A1c] in combination with cTn to rule-in/rule-out MI and other major cardiovascular events (MACE) to facilitate early decision-making in the ED. This thesis demonstrates that a combination of cTn and glucose at presentation is both an efficient and cost-effective tool for early decision-making in the ED.

Background: The emergency department is available all hours of the day for patients who have suffered an acute injury or illness. The nurses' experience work in the emergency department as hectic and stressful. Heavy workloads and overcrowding make the nurses feel anxious and frustrated that they cannot provide optimal care to the patients. According to chosen nursing scientific theory, care can be experienced as caring or uncaring. Laws and governing documents that the health and medical care must comply with and the nurses' area of responsibility appear. Aim: To describe patients’ experiences of care in the emergency department. Method: General literature review based on eleven articles with a qualitative approach and four articles with a quantitative approach. Results: Six categories were identified in the analysis; The importance of communication, The importance of information, The importance of the encounter, The importance of security, the importance of time spent waiting and the importance of surroundings. It emerged that the patients' experiences of being cared for in the emergency department varied. The patients experienced a lack of communication and information. The patients experienced different encounters, long waiting times and a hectic environment. These experiences resulted in anxiety and discomfort. When the nurses were well versed in their work, the patients felt more secure and trusted the nurses. Conclusion: Positive and negative experiences are identified by patients in the emergency department. The healthcare staff needs continuous training, improvement of the environment is required to improve the patients' experience of care.

Registered nurse (RN) insufficiency is both a major contributor to and effect of emergency department overcrowding (EDOC) in the United States and is implicated in increased patient mortality, ED wait times, and general congestion of the healthcare system. Licensed paramedics represent a viable solution to this crisis given their extensive training in emergency care by serving as RN adjuncts and alternatives in the ED setting. Paramedics utilize high-level clinical judgment and patient assessment skills to form detailed clinical impressions and employ a wide range of therapies to initiate treatment. Although they less frequently possess a college degree than their RN counterparts, paramedics complete a comparable study of medical science principles, patient assessment, and pathophysiology, and devote significantly more time to critical care and emergency medicine than RNs. Implementation of paramedics in U.S. EDs in the 1980s and 1990s highlighted their manual and technical skill prowess as well as their ability to rapidly assess emergency situations, including their unexpectedly widespread use in pediatric EDs. Modern implementation includes expansion of the psychomotor skills available to ED-based paramedics, with emphasis on medication administration and emergency procedures, but there is a significant lack of research into paramedic assessment and triage skills in the ED. Barriers to further implementation of ED paramedics include resistance from nursing advocacy organizations, regulatory and legal challenges, and public opinion and attitudes of nurses and paramedics. Nursing advocacy groups have historically opposed paramedic integration, fearing job encroachment and increased autonomy for non-nursing healthcare professionals. Regulatory challenges involve certification vs licensure discrepancies, limitations on paramedic scope of practice, and the wide-reaching effects of state Nurse Practice Acts. Societal resistance, cultural factors, and attitudes within the nursing and paramedic communities also impede further ED paramedic implementation. Practice recommendations are proposed, including the development of standardized ED orientation programs for paramedics, and redefining the minimum education for paramedics at the associate degree level. Legislative recommendations involve eliminating statutory restrictions on paramedic practice, reevaluating language in state Nurse Practice Acts, and clarifying the legal relationship between RNs and ED paramedics. The limitations of this literature-based thesis include a lack of large-scale studies, regional variability, and the absence of empirical examination of paramedic integration in reducing ED overcrowding. Future suggestions for study include randomized controlled trials comparing ED patient outcomes between RNs and paramedics, interrater reliability studies on assessment and triage skills, and comparisons of scope of practice and education between paramedics in different countries.

Yes / The most common route to a hospital bed in an emergency is via an emergency department (ED). Many recent initiatives and interventions have the objective of reducing the number of unnecessary emergency admissions. We aimed to assess whether ED admission thresholds had changed over time taking account of the casemix of patients arriving at ED. Methods: We conducted a retrospective cross-sectional analysis of more than 20 million attendances at 47 consultant-led emergency departments in England between April 2010 and March 2015. We used mixed- effects logistic regression to estimate the odds of a patient being admitted to hospital and the impact of a range of potential explanatory variables. Models were developed and validated for four attendance subgroups : ambulance-conveyed children; walk-in children; ambulance-conveyed adults; and walk-in adults. Results: 23.8% of attendances were for children aged under 18 years, 49.7% were female and 30.0% were conveyed by ambulance. The number of ED attendances increased by 1.8% per annum between April 2010 – March 2011 (year 1) and April 2014 –March 2015 (year 5). The proportion of these attendances that were admitted to hospital changed little between year 1 (27.0%) and year 5 (27.5%). However, after adjusting for patient and attendance characteristics the odds of admission over the five year period had reduced by: 15.2% (95% CI 13.4% - 17.0%) for ambulance-conveyed children; 22.6% (95% CI 21.7%-23.5%) for walk-in children; 20.9% (95% CI 4%-21.5%) for ambulance conveyed adults; and 22.9% (95% CI 22.4%-23.5%) for walk-in adults. Conclusions: The casemix-adjusted odds of admission via ED to NHS hospitals in England have decreased since April 2010. EDs are admitting a similar proportion of patients to hospital despite increases in the complexity and acuity of presenting patients. Without these threshold changes, the number of emergency admissions would have been 11.9% higher than was the case in year 5.

Influenza is a highly contagious respiratory virus that can cause very severe health complications in people, and can be especially dangerous for young children. The peak influenza season occurs in the winter months with February usually being the month with the highest number of reported infections. As the virus can cause serious illness, pediatric institutions during the winter months see a very large number of patients who have influenza or influenza related complications. Pediatric Emergency Departments (ED) similarly see a dramatic increase in the number of patients who visit the ED during the winter influenza season. Therefore, it is important that pediatric EDs develop ways to handle the increased patient population while still maintaining quality care to the rest of the ED. Thus, a novel influenza clinic run entirely by non-ED Nurse Practitioners (NP) was implemented into the operations of the ED as an annexed clinic in February 2013 during the winter influenza season. The clinic was beneficial in improving the average quality measures of the ED against similar days without the influenza clinic, lowering the average length of stay (LOS) by 24 minutes (13% decrease) and lowering the left without being seen rates (LWBS) by 1.35% (3 fewer patients on average). In addition, using NPs instead of higher cost physicians dramatically lowered the cost of the clinic by nearly half. While the influenza clinic was beneficial in lowering the average LOS and LWBS rates against similar days without the clinic the data did not reach statistical significance, perhaps due to the small amount of data available. The results, despite the statistical insignificance, show a promising future in addition of an NP run influenza clinic to handle the increased patient population during the winter influenza season.

Primary-care-related emergency department (PCR-ED) visits by Hispanic patients enrolled in a not-for-profit Medi-Cal and Medicare health plan resulted in longer wait times in the emergency department (ED) at a regional medical center in Southern California. This congestion decreased access for those with true emergencies, created capacity issues, increased ED length of stay, and resulted in potential safety risks. This project focused on decreasing PCR-ED visits in the Hispanic population using patient navigators in Southern California. Applying the health belief model and Lippitt's theory of change, this doctoral project involved the creation and implementation of a culturally appropriate, population-specific patient navigator model for the Hispanic population. Evaluation of outcomes was accomplished using electronic health record (EHR) results, which demonstrated a reduction of PCR-ED visits and revisits. The project exceeded the goal of 10% reduction in PCR-ED visits and revisits in the target population and resulted in a 14.31% reduction of PCR-ED visits and revisits within 1 month of implementation. Emergency Severity Index levels, wait time associated with each Emergency Severity Index level, and visits of the targeted Hispanic population enrolled in the health plan were analyzed to evaluate the success of the program. This project may lead to improvements in nursing practice and positive social change by supporting population health management and continuum of care to a primary care physician through safe and efficient patient navigation to treatment and care.

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Bakgrund: Vårdpersonalen på en akutmottagning har stora krav på sig, ansvar för många patienter och måste fatta många egna beslut, ibland med mycket kort betänketid. Vårdpersonalen möter många olika patienter med olika problem och personligheter, och måste bemöta varje patient så att denne känner sig bekräftad och sedd. Syfte: Syftet med litteraturöversikten är att undersöka patienters upplevelse av att vårdas på en akutmottagning. Metod: Artiklar till arbetet har söks i olika databaser. Aktuella artiklar har lästs och relevanta fynd har markerats, för att analyseras och sammanställa ett resultat. Resultat: Analysen resulterade i tre underrubriker: Information, Bemötande och Vårdmiljö, med uppdelning av positiva och negativa upplevelser. Många patienter var nöjda med vården, men hade låga förväntningar från början. Patienterna har förstående för personalens tuffa arbetsmiljö, men önskade att få bättre information om väntetid och undersökningar. De tyckte att väntetiden var för lång, och kände sig ofta ensamma och övergivna. Slutsats: Mycket behöver förändras för att patienterna ska få en mer positiv upplevelse av akuten. Detta arbeta kan hjälpa till att belysa vilka punkter som vården måste arbeta extra mycket med för att patienterna ska känna sig trygga, exempelvis bättre information om väntetider och ett bemötande där sjusköterskan ser hela patienten. / Background: The demands and expectations on a nurse in the emergency room are high. They are responsible for many patients and have to make many decisions on their own, sometimes with very short reflection time. They face a wide variety of patients with different problems and personalities, each requiring their own method of approach and interaction in order for him or her to feel acknowledged. Aim: The aim of the literature review is to examine patient's experiences of being cared for in an emergency room. Method: Articles for the work has been searched in different databases. Articles in-question has been read and the relevant finding has been highlighted, to analyze and compile the results. Results: The analysis resulted in three subheadings: Information, Treatment and Care environment, with sectioning of positive and negative experiences. Many patients were satisfied with the care, but had low expectations from the start. Conclusion: There is much that needs to be changed to allow patients to have a more positive experience of the emergency room. Care units must work harder with to ensure that patients will feel secure and safe, for example, better information on waiting times and a treatment where the nurse sees the whole patient.