The purpose of this study was to determine whether a coordinated and comprehensive system of care for the uninsured changed the behavior of the uninsured by decreasing non-urgent utilization of the emergency departments within a large, urban county. The literature on emergency department trends and interventions designed to decrease "inappropriate" or non-urgent use of the emergency departments was reviewed and links to relevant theoretical concepts were identified. Utilization data from six emergency departments and six federally qualified health centers were evaluated. Secondary data over a three-year time period were abstracted from patient and organizational records at the hospitals and federally qualified health centers. The utilization data from the emergency departments and health centers were compared. The analysis revealed a significant change in the number of non-urgent visits by self-pay patients at the emergency departments when the health centers expanded. A 32.2 percent decrease in utilization of the emergency departments by self-pay patients was found. Non-parametric tests demonstrated significant differences in the population seen at the emergency departments and the clinics over the three-year study period. Regression analysis demonstrated a statistically significant decrease in non-urgent, self-pay visits at the emergency departments as a result of the increase in self-pay visits at the federally qualified health centers. Further analysis includes forecasting the impact of future federally qualified health centers on emergency department utilization. Recommendations for future research include evaluation of the increased numbers of non-urgent transports from the local emergency medical system by self-pay patients as well as the design of a pilot study to look at the effectiveness of transporting these patients to the federally qualified health centers for care instead of to the local emergency departments.

With healthcare organizations struggling to remain competitive and financially stable in a market where minimizing costs is a priority, hospital administrators feel the sense of urgency when it comes to keeping patients satisfied with services in order to expand volume and market share. The Emergency Department is considered the front door of a healthcare organization, and keeping its visitors satisfied in order to guarantee a future visit or a referral to a friend or family member is a must. While patient input on the services received in a healthcare facility is essential to improving quality of care, the costs associated with measuring, collecting and analyzing their feedback are remarkable. This research focuses on developing a linear regression model to predict patient satisfaction in the ED using surrogate measures related to patient's socio-demographic characteristics and visit characteristics. With a model of this kind, healthcare administrators can potentially eliminate survey costs while still being able to determine where the hospital stands in the eyes of the patient. Three modeling approaches were used to develop a multiple regression equation. Modeling approach 1 used monthly patient satisfaction scores as the dependent variable collected by a third-party survey organization. The goal of this model was to predict monthly patient satisfaction scores. Modeling approach 2 used patient satisfaction scores collected by the discharge registrar prior to the patient leaving the ED. The goal of this model was to predict patient satisfaction scores on a patient-by-patient basis. Modeling approach 3 used patient satisfaction scores collected by a third-party survey organization. The goal of this modeling approach was to predict patient satisfaction scores on a patient-by-patient basis. Each modeling approach developed in this study used its own survey tool. Though this study had limitations when it came to developing the models and validating the findings, results are very promising. Analysis shows that predicting average patient satisfaction scores on a monthly basis gives the most accurate results, with socio-demographic characteristics and visit characteristics explaining 96% of variation in monthly average patient satisfaction scores. Other model indicators, such as normality of residuals, predicted error, mean square error, and predicted R-square show that the model fits the data very well and has strong predictive ability. Models that attempted to predict patient satisfaction on a patient-by-patient basis appeared to be ineffective, with very large predicted errors and prediction intervals and low predictive ability.

Emergency departments in Sweden are usually struggling with long waiting times, delays and bottlenecks in the system. The National Board of Health and Welfare and the County Council of Västra Götaland have established to decrease the average time a patient stays in an emergency department as important priority as well as the waiting time to be seen by a nurse and by a physician. Healthcare systems are usually characterized by its complexity because of the variability and stochastic nature of the different processes involved in the flow of patients, staff and resources. In order to increase the use of the existing resources and to reduce the waiting times of patients, a system improvement methodology involving discrete-event simulation and process analysis has been used. In this project a computer-based simulation tool was applied at the emergency department of the hospital Kärnsjukhuset in Skövde, which belongs to Skaraborgs Sjukhus and is one of the largest emergency departments in the region of Västra Götaland. A three-dimensional model was created to help visualize and understand the problems, as well as to identify improvements by the different stakeholders involved. Continually, the simulation model was modified to test possible improved scenarios with the aim to increase the service level of the system.  The design, implementation and analysis of these scenarios have provided decision makers of the emergency department with the necessary information to implement or reject the ideas of the different improved scenarios. Some of these scenarios had a significant impact with small changes so they were implemented in the real system; some others had non-significant impact in the results so they were not implemented. The main result of this project has been to identify which system changes will lead to a reduction of the different waiting times of patients. In addition, the simulation and experiments of future solutions show a more efficient use of the existing resources. This design of a better configuration of the system gives Kärnsjukhuset the possibility to increase the service level of the system and to meet some of the requirements established by the County Council. This project shows that the use of simulation tools provides enormous benefits for healthcare system analysis and improvement; new ideas and scenarios can be designed without disturbing the normal activities of the hospital, saving considerable time, money and resources.

BACKGROUND: The Emergency Department is a quick-moving environment in which rapid identification of illness and prompt treatment is the mainstay of care. Obtaining informed consent from a patient for a high-risk or invasive procedure is required both legally and ethically regardless of the setting. However, informed consent in the Emergency Department is routinely inadequate. LITERATURE REVIEW: Research thus far has identified several of the barriers to obtaining proper informed consent; a few including language barriers, gaps in intellectual levels, fragmented care of different emergency providers, vulnerability of patients in the ED, and the complexity of the informed consent forms. Investigation into improving the informed consent discussion and patient comprehension has shown promise in implementing patient centered modalities that aid in communication. Such modalities include repeat-back mechanisms, easy-read documents, and implemented multimedia presentations. PROPOSED PROJECT: In this proposed study, we will focus on a pre-intervention (control) group and an intervention group. The intervention to be implemented will be a paracentesis informed consent video and a provider checklist including procedure, diagnosis/intervention, risks, benefits, and alternatives all to be checked off after being discussed with and repeated back by the patient. Patient understanding will be analyzed using a post-discussion questionnaire completed by all participants. We hypothesize that this intervention will improve overall comprehension of the informed consent discussion regarding the paracentesis procedure. CONCLUSION: Patient comprehension of the informed consent discussion in the Emergency Department is often lacking in meeting both legal and ethical standards. Reviewing the data for a significant change between the control and intervention group will allow us to determine if enhancing the informed consent discussion to a more patient-centered process will improve patient understanding of all aspects of the informed consent discussion. In the end, this will guarantee ED patients their lawful right to truly informed consent. SIGNIFICANCE: This informed consent video and checklist will allow for an informed consent process that remains standardized but is more patient focused to improve patient comprehension of the process and protect the rights of all parties involved.

Bakgrund: Akutens unika miljö präglas av snabba beslut kring svårt sjuka och skadade patienter. Trots att det finns evidens att omvårdnad är bärande för patientsäkerheten hamnar det ändå ofta i skuggan av den medicinska behandlingen på akuten. Syfte: Att belysa sjuksköterskors erfarenheter av hur arbetsmiljöfaktorer kan påverka omvårdnaden på en akutmottagning. Metod: En litteraturstudie med kvalitativ ansats skapades. Datainsamlingen utgjordes av strukturerade sökningar i databaserna CINAHL och PubMed. 16 empiriska kvalitativa artiklar granskades med hjälp av en granskningsmall för kvalitativ forskning. Därefter gjordes en tematisk kategorisering och analys av de 10 artiklar som framkom av datainsamlingen efter urval. Resultat: Två huvudteman och sex underkategorier framkom. Det första huvudtemat var: den fysiska arbetsmiljön med underkategorierna arbetsmiljön på akutmottagningen, när omvårdnaden brister och patientsäkerhetsarbetet. Det andra huvudtemat var: den organisatoriska & den sociala arbetsmiljön med underkategorierna äldre och anhöriga på akuten, bilden av sjuksköterskan och samverkan i team. Slutsats: Genomgående i resultatet finns bevis för att arbetsmiljön och brist på resurser leder till att omvårdnadsarbetet prioriteras bort. För att främja det viktiga omvårdnadsarbetet på akuten krävs förbättringar i sjuksköterskans arbetsmiljö. / Background: The unique environment of the emergency department is characterized by quick decisions regarding critically ill and injured patients. Despite the fact that there is evidence that nursing is essential for patient safety, it is still often overshadowed by medical treatment. Aim: To highlight nurses’ experiences of how factors related to the work environment can affect care in an emergency department. Method: A literature study with a qualitative approach was created. The data collection consisted of structured searches in the databases CINAHL and PubMed. 16 empirical qualitative articles were reviewed using a review template designed for qualitative research. Lastly, a thematic categorization and analysis of the 10 articles that emerged from the data collection after selection was made. Result: Two main themes and six subcategories emerged. The first main theme was: the physical work environment with the subcategories: the work environment in the emergency department, lack of nursing care and patient safety work. The second main theme was: the organizational & social work environment with the subcategories elderly and relatives in the emergency department, the nursing image and cooperation in teams. Conclusion: Throughout the results there is evidence that the work environment and lack of resources lead to nursing care being deprioritized. In order to promote the important nursing care in the emergency department, improvements are required.

Resource management is at the heart of many diverse science and engineering research areas. Although the general notion of what constitutes a resource entity seems similar in different research areas, their types, characteristics, and constraints governing their behavior are vastly different depending on the particular domain of research and the nature of the research itself. Often research related to resource modeling and management focus on largely homogeneous resources in a relatively simplified model of the real world. The problem becomes much more challenging to deal with when working with a complex real life domain with many heterogeneous resource types and intricate constraints. In this dissertation, we have looked at the modeling and management of resource instances and tried to develop a better sense of what makes them different from other objects in a system. As part of this work, We formally define the general resource management problem, identify its major sub problem areas and their associated complexities, and look at the problem in the context of a particularly complex and dynamic environment, namely the emergency department (ED) of a hospital. We propose an approach to the problem and some of its complexities by presenting an overall unifying view, as well as tools and methods for dealing with, this pervasive, yet surprisingly under examined, type of entity, i.e. resources. We have discovered that one of the discerning characteristics of resource instances in complex and dynamic environments seem to be their dynamic capability profile that may changes depending on system context. This, in turn, often results in complex substitutability relationship amongst resource instances. We have identified four major sub-problem areas that can provide a holistic view of any resource management service. These separate, yet interconnected, areas of con- cerns include resource modeling, resource request specification, resource constraint management, and resource allocation. Resource modeling involves capturing of re- source characteristics and their potentially dynamic behavior. Request definitions describe how resource users specify requirements for resources in a particular do- main. In most domains, there are constraints that need to be satisfied while serving resources to fulfill specific requests. The fourth area of concerns, the allocation of resources, is a complex component with multiple subcomponents that closely inter- act with each other. In this thesis, we have described an architecture for a exible resource management service based on the above described separation of concerns. We have proposed some simple, yet effective, techniques for modeling resource in- stances, specifying resource requests, specifying and managing resource constraints, and allocating resource instances to meet a resource demand characterized by a con- tinuous stream of requests. Using our proposed design, we have developed ROMEO, a resource management service and customized it to serve a task coordination frame- work based on Litlle-JIL process definition language. Our work then concentrated on evaluating the effectiveness of ROMEO in supporting simulations and executions of complex processes. For this evaluation purpose, we developed a simulation infras- tructure named JSim on top of Juliette, Little-JIL's execution environment. We ran a variety of simulations of patient care processes in EDs using our ROMEO-JSim infrastructure. We also used ROMEO to support the actual execution (rather than just the simulation) of a large mediation process. A central premise, hypothesized and explored in this thesis, is a novel way of thinking about resource instances in dynamic domains, namely defining them with a set of guarded capabilities, some of which may be dependent on the execution state of the system. This has led us to think about how to represent execution states of a running system and what types of system state information might be important for representing the guard functions on the capabilities of a resource instance that define the resource instance's ability to satisfy a request at a given execution state of the system. We have also identified a small set of common types of attributes of resource instances that seem able to support specification of a large variety of resource instances in complex domains. We believe that our research supports our hypothesis that specifying resource instances as having sets of guarded capabilities provides a useful abstraction for modeling many of the complex dynamic behaviors of resource instances in such domains as hospital EDs.

Bakgrund: Sjuksköterskor är skyldiga att arbeta evidensbaserat för att ge säker vård utifrån patientens behov. Utmärkande för en god vård är ett vårdande som möter varje patient så öppet och följsamt som möjligt. Att skapa ett vårdande möte till barn när de är patienten kräver att sjuksköterskan skapar tillit och en god relation till barnet för att ge god och säker vård. Syfte: Syftet är att undersöka sjuksköterskors upplevelser av att vårda barn som inkommer till akutmottagning. Metod: En allmän litteraturöversikt valdes som metod för det här examensarbetet. En allmän strukturerad sammanställning över de omvårdnadsområden som kan vara relevanta för sjuksköterskors upplevelser av att vårda barn som inkommer till akutmottagning. Resultat: Sjuksköterskorna upplevde att hur de arbetade och hanterade situationer med barn hade betydelse för vad mötena resulterade i. Att vårda barn på akutmottagningar kan hos sjuksköterskor skapa känslor av otillräcklighet och osäkerhet i pressade situationer. Tidsbrist och underbemanning är faktorer som kan leda till minskat förtroende samt minskad möjlighet att skapa trygghet i möten med barn. Konklusion: Att möta och vårda barn på akutmottagning innebär för sjuksköterskan att arbeta med ett vårdande förhållningssätt. Personcentrerad vård är grundläggande ochinkludering av föräldrar bidrar till ökad trygghet för barnet. / Background: Nurses are obliged to work based on evidence to provide safe care based on the patient's needs. Care that meets each patient as openly and compliantly as possible is the hallmark of good care. Creating trust and a good relationship with the child is a prerequisite for being able to give the child good support and good help. Aim: The purpose is to investigate nurses' experiences of caring for children who come to the emergency department. Method: A general literature review was chosen as the method for this thesis. A general structured summary of the nursing areas that may be relevant to nurses' experiences of caring for children who come to the emergency department. Findings: The nurses experienced that how they worked and handled situations with children was important for what the meetings resulted in. Caring for children in emergency departments is experienced by nurses as feelings of inadequacy and insecurity in stressful situations. Lack of time and understaffing are factors that can lead to reduced trust and a reduced opportunity to create security in meetings with children. Conclusion: Meeting and caring for children in the emergency department means for the nurse to work with a nurturing approach. Family-centred care is fundamental as the inclusion of parents contributes to increased security for the child.

No description available.

Introduktion: Akutmottagningen är platsen människor kommer när de drabbats av akut skada eller sjukdom. Utmaningar kan uppstå i individanpassat bemötande som är viktigt för att skapa trygg, personcentrerad vård och god vårdrelation. Utmaningen som kan leda till brister i patientsäkerheten kan eventuellt förebyggas genom förståelse för patienters perspektiv kring bemötande. Denna litteraturöversikts syfte var därför att beskriva patienters upplevelse av bemötande på akutmottagning. Metod: Litteraturöversikten innehöll tio kvalitativa originalartiklar. Dessa valdes efter litteratursökning i databaserna CINAHL och PubMed och kvalitetsgranskades med SBU:s granskningsmall för kvalitativa studier. Resultatanalys gjordes utifrån metod beskriven av Popenoe et al. (2021). Resultat: I resultatet framkom två teman: Att bli sedd som innehöll kategorierna, ”Att känna sig respekterad”, ”Att känna sig som en egen person” och ”Att känna sig uppmärksammad” och Att uppleva säkerhet och delaktighet med kategorierna: ”Att få information” och ”Att ha en öppen kommunikation med vårdpersonal”. Positiva upplevelser av bemötande handlade ofta om när patienten kände sig sedd, uppmärksammad och delaktig. Negativa upplevelser handlade ofta om bristande information och kommunikation vilket ledde till upplevelser av osäkerhet. Slutsats: Upplevelser av bemötandet på akutmottagningen beskrevs genom olika påverkande faktorer kring kommunikationens dimensioner; att vara informerade och delaktiga i sin vård. Vårdpersonal på akutmottagningen är skyldiga att hålla patienter informerade och delaktiga i sin vård. Patienters upplevelse av vårdpersonalens bemötande är viktigt för vårdförloppet och gör att människor känner sig trygga att söka vård på akutmottagningen. / Introduction: The emergency department is where people go if they suffered an acute injury or illness. Challenges can occur around person-centered care which is needed for a good care relationship. This patient safety risk could be preventable through understanding of patients’ experience of care encounters. The purpose of this literature review was to describe patients' experience of care encounters in emergency departments. Method: The literature review contained ten qualitative original articles. These were selected after a literature search in the databases CINAHL and PubMed, quality reviewed using SBU's template for review of qualitative studies. Result analysis was made according to the analysis method described by Popenoe et al. (2021). Results: Result showed two themes: Being seen with the categories; "To feel respected", "To feel like an individual" and "To feel noticed" and Experiencing safety and participation with the categories: "Getting information” and “Having an open communication with healthcare staff”. Positive experiences was when the patient felt seen, noticed as an individual and involved. Negative experiences were about lack of information and inadequate communication, which led to uncertainty. Conclusion: Patients' experiences of encounters in the emergency department varied and were described through positive and negative factors in the dimensions of communication; to be informed and involved in their care. Healthcare staff are responsible for keeping patients informed and involved in their care. Patients' experience of care staff encounters is important for the care process and makes people secure when seeking care at emergency departments.

Bakgrund Våld mot kvinnor i nära relationer orsakar stort lidande hos individen samt deras familj. Våldsutsatta kvinnor har behov av stöd och förståelse från hälso- och sjukvården. Våldet som orsakas mot kvinnorna leder till behov av akutsjukvård och därmed krävs rätt beredskap hos sjuksköterskor som arbetar på akutmottagning. Syfte Syftet med litteraturöversikten är att sammanställa aktuell forskning kring sjuksköterskans erfarenheter av att möta kvinnor på akutmottagning som utsatts för våld i nära relationer. Metod Detta är en strukturerad litteraturöversikt med inslag av den metod som används i systematiska översikter. Denna litteraturöversikt baseras på kvalitativa och kvantitativa studier som analyserats och likheter har kategoriserats vilket medförde till resultatet. Resultat Huvudkategorier identifierades; Förutsättningar hos sjuksköterskor samt Faktorer som påverkar sjuksköterskans bemötande med tillhörande underkategorier. Sammantaget påvisades en brist på kunskap, riktlinjer, rutiner samt tid hos sjuksköterskorna på akutmottagningarna vid omvårdnad av kvinnor som blivit utsatt för våld i nära relation. Sjuksköterskorna hade behov av vidare utbildning samt resurser för att kunna ge adekvathjälp. Slutsats Utbildning och organisatoriska förändringar som rutiner samt riktlinjer bör införas för att sjuksköterskor ska få adekvat kompetens och resurser för att identifiera samt möta våldsutsatta kvinnor och kunna ge god omvårdnad. / Background Intimate partner violence against women causes great suffering for the individual and their family. Women exposed to violence need support and understanding from the healthcare system. The violence that is caused against women leads to the need for emergency medical care, which requires adequate preparedness from nurses who work in the emergency department. Aim The aim of the literature review is to compile current research on the nurse's experiences of meeting women in the emergency department who have been exposed to intimate partner violence. Method This is a structured literature review with elements of the methodology used in it systematic reviews. This literature review is based on qualitative and quantitative studies that were analysed and similarities between these have been categorized which led to theresult. Results Main categories were identified; Presumptions for nurses and Factors that affect the nurse’s response with associated subcategories. Overall, there was a lack of nurses’ knowledge, time, guidelines, and routines in the emergency departments when caring for women who have been exposed to intimate partner violence. The nurses needed further education and resources to be able to provide adequate help. Conclusions Education and organizational changes such as routines and guidelines should be established so that nurses will have adequate skills and resources to identify and meet abused women and be able to provide good care.