Effective communication among clinicians is critical for patient safety. This multi-site observational study analyzes inter-clinician communication and interaction with information technology, with a focus on the critical process of patient transfer from the Emergency Department to General Internal Medicine. The study provides insight into clinician workflow, evaluates current hospital communication systems, and identifies key issues affecting communication. It suggests opportunities for improvement: • extending the role of the electronic patient record, • rendering it available on a mobile platform, • developing an improved paging system. It also identifies design trade-offs to be negotiated: • synchronous communication vs. reducing interruptions, • notification of patient status vs. reducing interruptions, • portability vs. screen size of mobile devices, • speed vs. quality of handovers, • information privacy vs. accessibility. The results inform the potential development of an intervention meeting seven principles: interconnectivity, context awareness, accessibility, redundancy, user customization, security, and intuitive user interfaces.

Designing a software interface for healthcare requires thorough domain knowledge, and effective user research and benchmark analysis. This thesis examines the requirements for an improved patient information management system for emergency medicine and describes the iterative process of designing and evaluating the system. I conducted observational study of Emergency Department (ED) physicians’ workflow and information needs, from which I derived a set of functional requirements, created scenarios, performed hierarchical task analysis, and developed a preliminary user model for the patient information management system. Based on these, I developed an interface prototype and evaluated the design with a sample of ED physicians. I review the user testing and design iterations carried out and report on the design improvements made based on the user feedback.

Effective communication among clinicians is critical for patient safety. This multi-site observational study analyzes inter-clinician communication and interaction with information technology, with a focus on the critical process of patient transfer from the Emergency Department to General Internal Medicine. The study provides insight into clinician workflow, evaluates current hospital communication systems, and identifies key issues affecting communication. It suggests opportunities for improvement: • extending the role of the electronic patient record, • rendering it available on a mobile platform, • developing an improved paging system. It also identifies design trade-offs to be negotiated: • synchronous communication vs. reducing interruptions, • notification of patient status vs. reducing interruptions, • portability vs. screen size of mobile devices, • speed vs. quality of handovers, • information privacy vs. accessibility. The results inform the potential development of an intervention meeting seven principles: interconnectivity, context awareness, accessibility, redundancy, user customization, security, and intuitive user interfaces.

No description available.

Alcohol and drug abuse are strong predictors of suicide. While screening methods have proven effective at identifying and treating substance abuse in non-treatment-seeking users (e.g., screening and brief intervention [SBI]), less attention has been given to the co-occurrence of suicidality among this population, including its correlates and etiology. The current study addresses this gap by presenting data from early adult emergency department (ED) patients (mean age = 27; N = 505), screened for substance abuse and suicidal ideation. Prevalence of past year ideation was high (15%). Results demonstrated a significant and positive indirect effect of cocaine use severity on likelihood of suicidal ideation, mediated through family support. The implications for SBI practices in the ED and suicide etiology among non-treatment-seeking substance abusers are discussed.

Purpose: The purpose of this dissertation was to examine the determinants of unplanned emergency department (ED) use by home care clients, the profile of older ED patients, their transitions from the ED, as well as the determinants of post discharge outcomes among older ED patients. The goal of this dissertation was to create theoretically driven, evidence-based, and practical risk identification methods for home care and the ED. Methods: First, a multi-year, census-level cohort study was conducted on home care clients in two Canadian provinces (N=617,035). Census-level data from RAI-HC assessments were linked to census-level ED records. A needs-based decision tree model – the ED Model – informed by the Andersen Behavioural Model, was created using decision tree analyses. The final model was validated on a separate data partition and compared to the ERA Index and the CARS. Multilevel analyses were conducted to test regional variation in model performance. Disease stratified analyses were also conducted to test model generalizability across common disease classes. Regression analyses determined the effect of predisposing and enabling factors within ED Model strata. Second, a multi-site, multi-province prospective cohort study was conducted, termed the Management of Older Persons in Emergency Departments (MOPED) Study, using a clinically representative sample of 2,101 older ED patients. The interRAI ED-CA was used to assess older ED patients, and a 90-day disposition was collected. The profile of older ED patents was examined. Best-subset regression analyses identified person-level determinants of acute inpatient admission. Two needs-based decision tree models – the ALC/LTC and ED Revisit Models – were created using decision tree analyses to determine the risk of ALC designation or LTC placement, and unplanned repeat ED visits, respectively. Both models were validated on separate data partitions. Multilevel analyses were conducted to test site-level variation in the models’ performance. Results: Overall, 41.2% of home care clients had at least one unplanned emergency department visit within 6 months of an assessment. Previous ED use, cardio-respiratory symptoms, cardiac conditions, and mood symptoms featured heavily in the ED Model. The ED Model provided moderate risk differentiation and clinical utility. It achieved an area under the curve of 0.62 (95% CI: 0.61-0.62) and showed clear differentiation in Kaplan-Meier plots using validation data. Multi-level analyses showed no regional variation. The ED Model significantly outperformed the similar tools specific to primary care with respect to overall accuracy and perceived clinical utility. Predisposing and enabling characteristics provided little added differentiation beyond evaluated need. The majority of older ED patients were dependent on others for basic tasks of daily living, and many had fragile informal care or lived alone. Triage acuity generally did not differentiate chronic geriatric disabilities and conditions. Previous ED or hospital use was associated with chronic geriatric disabilities and conditions as well as informal caregiver distress. The Admission Model found that multiple factors were associated with admission to inpatient acute care, including: acuity, instability, changes in ADL function, cognition, nutrition, and anhedonia. Overall, 20.7% of older ED patients admitted to acute care were designated ALC or discharged to LTC; whereas 39.5% of older ED patients discharged home had one or more repeat ED visits within 90 days. Cognitive, functional, and informal care indicators were predictive of ALC/LTC; whereas functional status and symptoms were predictive of repeat ED use. The ALC/LTC and ED Revisit Models provided good risk differentiation, achieving AUC’s of 0.74 (95% CI: 0.69-0.79) and 0.69 (95% CI: 0.63-0.74), respectively. The ALC/LTC and ED Revisit Models showed clear differentiation in Kaplan-Meier plots. Multi-level analyses showed no site-level variation in each models’ performance. Conclusions: This dissertation produced tangible and empirically-based risk assessment models for clinical practice in home care and the ED. The models developed in this dissertation can support the targeting of preventative services as well as better communication strategies between the ED and community supportive care, primary care, and inpatient acute care. Key questions related to the prevention of the risk pathways identified in each risk assessment model remain unanswered, and should be a focus of future research.

Bakgrund: Sjuksköterskor som arbetar på akutmottagningar möter dagligen patienter som är alkohol- eller narkotikapåverkade. När patienter kommer till akutmottagningen och är påverkade av alkohol eller narkotika förekommer det ofta våld. Det vårdvetenskapliga perspektivet i examensarbetet är Kaséns syn på vårdrelationen och delaktighet. Syfte: Syftet är att beskriva sjuksköterskors erfarenheter av att möta patienter som är påverkade av alkohol eller narkotika på akutmottagning. Metod: Sex narrativa intervjuer har genomförts med sjuksköterskor som arbetar på en akutmottagning i mellersta Sverige. Intervjuerna har analyserats enligt Lundman och Graneheims metod för kvalitativ innehållsanalys. Resultat: Sjuksköterskornas erfarenheter från mötet med patienter med missbruksproblematik är att de kan vara våldsamma och framförallt är det viktigt att tänka på hur man bemöter dem. De ständigt återkommande mötena med dessa patienter på akutmottagningen tar mycket av sjuksköterskornas tid. Blandmissbrukare som är påverkade av både alkohol och narkotika anses vara mest våldsamma och det finns ett uttalat behov av utbildning främst av nya narkotikapreparat som finns på marknaden. Slutsats: Sjuksköterskor bör eftersträva ett professionellt bemötande av patienter med missbruksproblematik. Däremot kan det vara svårt att finna tiden för samtal med dessa patienter. Sjuksköterskor utsätts ibland för våld och trakasserier i mötet med patienter med missbruksproblematik. Därför bör det ställas högre krav på säkerheten på akutmottagningar, för både vårdpersonal och patienter. / Background: Nurses working in emergency departments encounter patients that under the influence of alcohol or narcotics on a daily basis. When patients come to the emergency department under the influence of alcohol or narcotics, there is often violence involved. As the caring science perspective used Kaséns view of the caring relationship and the participation. Aim: The aim is to describe the nurses’ experiences of encountering patients that are under the influence of alcohol or narcotics, in the emergency department. Method: Six narrative interviews were conducted with nurses working in an emergency department in mid-central Sweden. The interviews were analyzed according to Lundman and Graneheim method for qualitative manifest content analysis. Results: The nurses’ experiences of encountering patients with substance abuse problems are that they can be violent and above all it's important to consider their response. These constant and reoccurring encounters with patients in the emergency department are time consuming for the nurses. Among the patients under the influence of both alcohol and drugs are considered to be the most violent and there is a clear and present need for training in narcotics available currently in society. Conclusion: Nurses should seek to respond professionally to patients with substance abuse problems. However, it can be challenging to find the time to talk with these patients. Sometimes nurses are subjected to violence and harassment in the encounters with patients with substance abuse problems. Therefore, higher standards should be set regarding the safety of emergency departments, for both health professionals and patients.

Beslutsprocessen vid triage är komplex och triageprocessen bör utföras noggrant. Vid akuta situationer måste snabba beslut tas, oftast med lite information. Det ska under kort tid samlas in data genom observation, frågor och kontroll av vitalparametrar. Syftet med studien var att belysa faktorer som påverkar sjuksköterskans triagering av barn på akutmottagning. Studien genomfördes som en litteraturstudie där 13 vetenskapliga artiklar analyserades. I resultatet framkom fyra kategorier: kompetens och erfarenhet hos sjuksköterskan vid triagering av barn, faktorer relaterat till barn och vitalparametrar vid triagering av barn, sjusköterskans kommunikation med barn och närstående vid triagering och beslutsstöd i form av triagesystem. Kontrollen av vitalparametrarna är en grund i triagering men den kan utgöra en otillförlitlig bas för en korrekt triagebedömning. Stor utmaning är i att identifiera avvikande vitalparametrar och ha kunskap om utveckling och beteende relaterat till barnets utvecklingsnivå. Triagering av barn ställer speciella krav på triagesjuksköterskan och på de triagesystem som används. Genom att tydliggöra sjuksköterskans kunskap och skapa en förståelse kring triagering av barn uppmärksammas barnets behov. Vårdverksamheten behöver satsa på utbildning och utveckling av ett triagesystem för barn för att öka patientsäkerheten. Ytterligare forskning behövs om vilka faktorer som påverkar sjuksköterskan i bedömningen av det sjuka barnet. / To make a triage decision is a complex process that should be conducted carefully. In emergency situations quick decisions must be made, often with little information about the patient. In a short time information about the patient should be collected through observation, questioning and monitoring of vital parameters. The purpose of this study was to elucidate factors that influence the nurse in the triage process of children in the emergency department. The study was conducted as a literature study in which 13 scientific articles were analyzed. The result revealed four categories: skills and experience of the nurse in triaging children, factors related to children and vital parameters in triaging children, the communication between the nurse and the child and relatives during triaging, decision support in form of a triage system. Monitoring of vital parameters sets the ground to the triage decision but it can be an unreliable basis for an accurate triage assessment. A major challenge is to identify abnormal vital parameters and to understand the development and behavior related to the child’s level of development. Triaging of children puts special demands on the triage nurse and the triage system that is used. By elucidating the nurse’s knowledge and by creating an understanding of triaging of children, more attention is drawn to the needs of the child. Health care institutions need to invest in education and development of triage systems for children to improve patient safety. Further research is needed on which factors that affect the nurse in the assessment of the sick child.

Bakgrund: Patienter och närstående som befinner sig på en akutmottagning har ofta gått igenom en första kritiska bedömning, där miljön kan vara rörig och patienterna ibland är svårt sjuka. Arbetsbelastningen på sjuksköterskan har de senaste åren ökat, med ett ökat patienttryck och högre krav på medicinsk-teknisk kompetens. Sjuksköterskan måste inneha kunskaper inom såväl omvårdnad som medicin, för att patienter och närstående ska uppleva den första kontakten som positiv. Syfte: Att beskriva patienters och närståendes upplevelser av omvårdnad på en akutmottagning. Metod: Författarna har gjort en litteraturöversikt där 14 vetenskapliga artiklar har studerats, analyserats och använts i resultatet. Åtta av artiklarna var kvalitativa, sex av dem var kvantitativa. Likheter mellan artiklarna eftersöktes och grupperades. Resultat: Sju teman identifierades. Dessa belyser patienters och närståendes upplevelser av bra och mindre bra möten på olika akutmottagningar. Sjuksköterskan ansågs medicinskt kompetent. Oförståelse för hur akutsjuksköterskans arbete såg ut, bristande tillgång till information om väntetider och önskan om att psykosociala behov tillgodosågs var återkommande aspekter som krävde förbättringar. Diskussion: Upplevelsen av omvårdnad diskuteras i relation till Travelbee’s teori som klarlägger mötet och kommunikationen mellan sjuksköterskan och patienten, där även betydelsen av närstående belyses. Diskussion förs även ur ett sjuksköterskeperspektiv med förslag på hur sjuksköterskan kan agera för att bedriva god omvårdnad. / Background: Patients and relatives at the emergency department often have gone through a first critical assessment, where the environment can be messy and the patients often are seriously ill. Recent years, the workload of the nurse has increased, with increased number of patients and demands on medical-technical skills. The nurse must possess skills in both nursing and medicine, for the first contact to be experienced as positive by patients and relatives. Aim: To describe patients’ and relatives' experiences of care at an emergency department. Method: The authors have made a literature review in which 14 scientific papers have been studied, analyzed and used in the result. Eight of the articles are qualitative, and six of them are quantitative. Similarities between the articles were searched for and divided into groups. Result: Seven themes were identified. These highlight patients’ and relatives' experiences of good and less good meetings at various emergency departments. The nurse was considered medical skilled. Lack of understanding how emergency nurses work looks, lack of access to information on waiting times and desire to psychosocial needs were recurring issues that required improvements. Discussion: The experience of care is discussed in relation to Travelbee’s theory that illustrates the meeting and the communication between the nurse and the patient, where the importance of relatives also is highlighted. Discussion is also brought from a nurse perspective with suggestions on how nurses can act to engage in good care.

The basis for this thesis involved a four month Accelerate Canada internship at the Grand River Hospital Emergency Department in Kitchener, Ontario. The Emergency Department (ED) Process Committee sought insight into strategies that could potentially reduce patient length of stay in the ED, thereby reducing wait times for emergency patients. This thesis uses discrete event simulation to model the overall system and to analyze the effect of various operational strategies within the fast track area of the emergency department. It discusses the design and development process for the simulation model, proposes various operational strategies to reduce patient wait times, and analyzes the different scenarios for an optimal fast track strategy. The main contribution of this thesis is the use of simulation to determine an optimal fast track strategy that reduces patient length of stay, thereby reducing patient wait times. Wait times were most significantly reduced when there was an increased physician presence/availability towards the fast track system. This had the greatest impact on the total time spent in the ED and also on queue length. The second most significant reduction to the performance measures occurred when an additional emergency nurse practitioner was supplemented to the fast track system. Accordingly, the nurse practitioner’s percent utilization increased. There was only one two-way interaction effect that was statistically significant in reducing the primary performance measure of wait times; however, the effect did not change the queue length, a secondary performance measure, by a significant amount. Finally, the implementation of a See-and-treat model variant for fast track had a negligible effect on both the average length of stay and queue length.