<p><strong>BACKGROUND: </strong></p> <p>Emergency Department (ED) visit rates for patients with symptomatic, recent onset atrial fibrillation or atrial flutter (RAFF) are on the rise, which in turn has resulted in high hospital admission rates (38-45%). Optimal management strategies need to be developed for reducing hospital admission rates.</p> <p><strong>STUDY QUESTION:</strong></p> <p>The primary objective of this study is to evaluate the effectiveness of a clinical pathway for the management of low-risk RAFF patients in the ED. The hypothesis is that an evidence-based clinical pathway will help ED physicians better manage AF patients and reduce hospital admissions.</p> <p><strong>STUDY DESIGN:</strong></p> <p>A prospective, blinded, stratified, two-arm cluster-randomized trial will be conducted. The intervention is a clinical pathway for the management of RAFF.</p> <p><strong>PRIMARY AND SECONDARY OUTCOMES:</strong></p> <p>The primary outcome of this trial will be the proportion of low-risk, RAAF patients admitted to the hospital from the ED. Secondary outcomes will include a range of safety outcomes.</p> <p><strong>STATISTICAL CONSIDERATIONS:</strong></p> <p>An intention-to-treat analysis will be conducted at the individual level using proportions and means according to the variable in question with an alpha level of 0.05 and power of 0.80 for the primary outcome. The cRCT (assuming a 30% RRR) will be conducted over a two year time period. A total of 13 clusters and 3500 ED visits will be recruited to each intervention arm.</p> <p><strong>SUMMARY:</strong></p> <p>This thesis explores the methodological issues relevant to the design of a cRCT evaluating a clinical pathway in the management of acute onset, low risk AF patients presenting to the ED.</p> / Master of Science (MSc)

The pediatric emergency department (PED) provides a unique environment to consider ethical issues faced in modern healthcare. Using a combination of personal reflections and a review of current literature, ethics within the PED is explored as it pertains to four categories: informed consent, health literacy, language barrier, and implicit bias. Parental consent is generally required for pediatric care, but there are exceptions encountered in the PED. Although children typically cannot provide consent, soliciting assent respects their autonomy and maturing cognitive development. Limited health literacy is a prominent issue in the U. S., yet healthcare information continues to be delivered in ways that do not adequately account for this. Change will necessitate creative solutions and reorientation to a focus on health equity and justice. Physician implicit bias may be related to a patient’s negative behaviors or inherent characteristics (e.g. race), and can result in adverse health outcomes for affected children. Physicians should confront their subconscious biases through introspection, open discussion, and implicit-bias training. Access to healthcare information in one’s native language is a basic human right protected by law. Use of qualified medical interpreters can alleviate disparities faced by patients with limited English proficiency, but may be underutilized in the PED. / Urban Bioethics

A particularly unhealthy and high-risk group of individuals at the intersection of the criminal justice and public health systems often cycle between arrest, jail, prison, public hospitals, emergency departments, homeless shelters, and similar institutions over time. This population, while relatively small, represents disproportionate public spending and complex, multidimensional needs. The overarching goal of the current study is to gain a deeper understanding of the patterns and dimensions of frequent cross-system involvement, or repeat cycling between the criminal justice and public health systems. Specifically, the overlap of arrest by police and contact with the ED was examined. A secondary goal was to illuminate what factors work together to encourage or differentiate between various patterns of cross-system cycling. Group-based trajectory modeling was used to determine patterns of arrest and ED contact among adults that accessed these systems in Camden, NJ between 2010 and 2014. These groups were then brought together to determine patterns of cross-system involvement with a focus on patterns representative of frequent cycling between arrest and the ED. These joint groups were then described in detail using descriptive and predictive methods. By comparing across different patterns of frequent cycling, it is clear that cross-system involved individual do not represent a homogenous group; nor is mental illness and substance abuse the only factors driving this overlap. The most frequent joint trajectory groups exhibited significantly more ED visits to address injuries including skull-related injuries, chronic physical health conditions, dental and skin issues, anxiety, depression, suicide attempts, substance abuse and co- and multimorbidity measured as chronic conditions experienced with behavioral health concerns and drug/alcohol abuse. Arrests for disorderly, drug and prostitution offenses were also significantly more prevalent among frequent cross-system cyclers when compared to groups with fewer system contacts. Many of these same factors were also more prevalent among a subsample of young adults aged 18 in 2010 with repeat contacts with both systems. These steps, together with qualitative interviews with service providers in the Camden community, illuminated important factors associated with more frequent arrest and ED contact. These are important contributions to criminological research as discussion is often restricted to behavioral health and is less often concerned with physical health, co- and multi-morbidity. This is also among the first research studies to dig deeper into specific diagnoses associated with frequent arrest and frequent cross-system cycling, among adults and young adults. Healthcare provider interviews were able to confirm that certain issues like dental and skin conditions, depression, anxiety and suicide attempts/ideation tend to increase in prevalence as system contacts accumulate. These are factors that could be targeted earlier in the lifecourse in order to reduce cross-system cycling – an important form of concentrated disadvantage and vulnerability on which to focus attention and resources. / Criminal Justice

The emergency department (ED) has often been considered the safety net of the American healthcare system. It earned this distinction because every person in the United States has access to a medical screening exam and stabilization at an ED regardless of their ability to pay. Unfortunately, over the past several decades, decreasing numbers of EDs and inpatient beds, coupled with increasing rates of ED usage, has led to crowding of EDs across the country. Crowding leads to unsafe conditions that may increase morbidity and mortality for patients, or cause patients to leave the ED without being evaluated by a physician. Essentially, crowding causes a barrier for patients to access their right to emergency evaluation. The problem of crowding is most pronounced in large urban communities, and these already frequently underserved patients suffer the most from the crowding burden. The main cause of crowding seems to be the boarding of admitted patients in the ED, however many often cite high rates of non-urgent patients presenting to the ED as a cause of crowding. Some have even suggested diverting non-urgent patients to help solve the problem of crowding. I became interested in this topic due to crowding concerns and initiatives to decrease the number of patients who left without being seen at my own institution. As I reviewed relevant research, I became aware of my own misconceptions and noted a trend of literature suggesting non-urgent patients are not the cause of crowding. Drawing on research from many different sources, paired with evaluation based on principles in bioethics, I have come to several conclusions. I believe the systematic diversion of non-urgent patients is unsafe, and that the unequal burden of ED crowding on urban communities represents an unjust barrier in access to care. We must continue to carefully research the demographics of patients frequently presenting to EDs to avoid perpetuating stereotypes about which types of patients are responsible for crowding. We should also look for ways to ease the crowding burden in urban communities. Additionally, we should take a qualitative assessment of our individual communities to determine if there are any particular reasons in our community that people choose to use the ED rather than other healthcare options. I believe these suggestions can be an important addition to the efforts already in motion to help reduce ED crowding and provide equitable access to emergency medical evaluation. / Urban Bioethics

Intimate partner violence (IPV) is a public health emergency and due to the often-hidden nature of IPV, it is not readily apparent who is a victim. However, a large proportion of victims are economically disadvantaged, and the emergency department is the first place where many patients present, whether it be for related or unrelated concerns. IPV is difficult to detect, and unfortunately, physicians are also notoriously poor at predicting who is a victim, especially in the emergency department. Because IPV is lethal, it is imperative to improve detection of victims and to intervene when they come forward. This paper seeks to elucidate future sustainable improvements in IPV detection and intervention in the emergency department. Findings indicate that universal computer screening in the emergency department followed by immediate intervention and contact with an IPV-specific advocate is a necessary step to start combating IPV. / Urban Bioethics

Thesis advisor: Monica O'Reilly-Jacob / Background: Emergency department crowding (EDC) is a major issue affecting hospitals in the United States and has devastating consequences, including an increased risk of patient mortality. Solutions to address EDC are traditionally focused on adding resources, including increased nurse staffing ratios. However, these solutions largely ignore the value of the experience and expertise that each nurse possesses and how those attributes can impact patient outcomes. This dissertation uses Benner’s Novice to Expert theory of professional development to describe how individual emergency nurse expertise influences patient length of stay in the emergency department and how it can be part of the strategy in addressing EDC.Purpose: The purpose of this program of research was to identify, articulate, and demonstrate a new approach to emergency nurse performance evaluation that integrates patient outcome data and emergency nurse characteristics. Methods: First, in a scoping review, we explored the different approaches to measuring nurse performance using patient outcome data and identified common themes. Second, a concept analysis introduced Emergency Nurse Efficiency as a novel framework to understand how emergency nurses can be evaluated using patient outcome data. Finally, a retrospective correlational study established the association between nurse expertise and emergency patient length of stay. Results: In Chapter Two of this dissertation, the researchers conducted a scoping review of nurse performance metrics and identified twelve articles for inclusion. We identified three themes: the emerging nature of these metrics in the literature, variability in their applications, and performance implications. We further described an opportunity for future researchers to work with nurse leaders and staff nurses to optimize these metrics. In Chapter Three, we performed a concept analysis to introduce a novel metric, called Emergency Nurse Efficiency, that is a measurable attribute that changes as experience is gained and incorporates the positive impact of an individual nurse during a given time while subtracting the negative. Using this measurement to evaluate ED nurse performance could guide staff development, education, and performance improvement initiatives. In Chapter Four, we performed a retrospective correlational analysis and administered an online survey to describe the relationship between individual emergency nurses, and their respective level of expertise, and their patients’ ED LOS. We found that, when accounting for patient-level variables and the influence of the ED physicians, emergency nurses are a statistically significant predictor of their patients’ ED LOS. A higher level of clinical expertise among emergency likely produces a lower ED LOS for their patients, and nurse leaders should seek to better understand these metrics for professional development and quality improvement activities. Conclusions: This dissertation made substantial knowledge contributions to the literature regarding the evaluation of individual emergency nurses and the influence that they have on patient outcomes. It established, first, that the measurement of individual nurse performance is varied and inconsistent; second, that considering emergency nursing as a team activity similar to professional sports results in a conceptual framework that can evaluate individual performance within a group context; and, third, that there is a relationship between the individual emergency nurse and their patients’ ED LOS, and that relationship can be further understood within Benner’s Novice to Expert theoretical model. We recommend that nurse leaders use these data as part of their strategy to decrease EDC. / Thesis (PhD) — Boston College, 2023. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

Bakgrund: Akutmottagningar är avsedda för personer med akut sjukdom ellerskada och en sjuksköterska som arbetar på akutmottagningen är grund- eller specialistutbildad. En akutsjuksköterska har en specialistutbildning inom akutsjukvård och förväntas självständigt kunna göra korrekta medicinskabedömningar. På akutmottagningar utförs triage som är en process där patientens medicinska angelägenhetsgrad bedöms utifrån anamnes, subjektiva symtom samt objektiva tecken och detta är centralt för att patienten ska få adekvat vård i rätt tid. Stress, osäkerhet och att vara under press är känslor som triagerande sjuksköterskor ofta upplever. Syfte: Syftet var att beskriva akutsjuksköterskors upplevelser av triage på enakutmottagning. Metod: En kvalitativ intervjustudie med induktiv ansats, där tolv deltagare intervjuades. Intervjuerna analyserades enligt Graneheim och Lundmans innehållsanalys. Resultat: Tre kategorier framkom: medvetenhet om sina styrkor och svagheter, arbetsklimatet hindrar och främjar samt komplexitet i patientmötet. Kategorierna resulterade i det övergripande temat: Triage - en mångfacetterad utmaning i ständigt lärande, som innebär att triage upplevs vara en utmaning som kräver expertis samt flexibilitet och genom rätt förutsättningar, medkänsla och ständigt lärande kan patientens behov mötas. Slutsats: Resultatet visar att erfarenhet och utbildning är viktigt inom triage, för säkrare och tryggare bedömningar. Även som akutsjuksköterska är det viktigt med kontinuerlig utbildning för fortsatt personlig utveckling. Arbetsmiljön och samspelet med kollegor upplevs också påverka kvaliteten på triage där vissa faktorer hindrar och andra främjar. För att öka arbetsglädjen behöver tryggheten i bedömningar stärkas och hindrande faktorer ses över för att skapa en ännu bättre miljö kring triage. / Background: Emergency departments are intended for individuals with acute illness or injury, and a nurse working in the emergency department has a bachelor’s or master’s degree. An emergency nurse has a master’s degree in emergency care and is expected to independently make accurate medical assessments. Triage, performed in emergency departments, is a process where the patient's medical urgency is assessed based on medical history taking, subjective symptoms, and objective signs, and this is essential for the patient to receive timely care. Stress, uncertainty, and feeling under pressure are emotions frequently experienced by triaging nurses. Objective: The aim was to describe emergency nurses' experiences of triage in an emergency department. Method: A qualitative interview study with an inductive approach was conducted, where twelve participants were interviewed. The interviews were analyzed using Graneheim and Lundman’s content analysis. Results: Three categories emerged: awareness of strengths and weaknesses, the work environment hinders and promotes, and complexity in patient encounters. The categories resulted in the overarching theme: Triage - a multifaceted challenge in continuous learning, indicating that triage is perceived as a challenge requiring expertise and flexibility, and through the right conditions, compassion, and continuous learning, patient needs can be met. Conclusion: The results show that experience and education are important in triage for safer and more confident assessments. Even as an emergency nurse, continuous education is crucial for personal development. The work environment and interaction with colleagues are also perceived to affect the quality of triage, with certain factors hindering and others promoting. To enhance job satisfaction, the confidence in assessments needs to be reinforced, and hindering factors need to be addressed to create an even better triage environment.

Bakgrund: Mötet mellan föräldrar och vårdpersonal spelar en stor roll vid omvårdnad av barn. För att säkerställa att detta sker på ett bra sätt tillämpas metoder som familjecentrerad omvårdnad. När sjuksköterskor tillfrågas om vikten av familjecentrerad omvårdnad och hur det appliceras framgår det att familjecentrerad omvårdnad inte tillämpas på ett bra sätt trots att det anses viktigt. Genom att bättre förstå hur föräldrar upplever mötet kan förbättringsområden identifieras. Syfte: Syftet var att beskriva föräldrars upplevelser av mötet med vårdpersonal vid pediatriska besök på akutmottagning. Metod: Allmän litteraturstudie enligt niostegsmodellen av Polit och Beck (2021) med sökningar i CINAHL och PubMed samt reflexiv tematisk analys enligt Braun och Clarke (2021). Resultat: Fyra teman och tolv subteman identifierades. Dessa teman var Kommunikation och bemötande, Känslor och upplevelser, Effektiv hälso- och sjukvård och resurser samt Miljö och närhet på mottagningen. Slutsats: Föräldrar beskrev överväldigande känslor i samband med besök på akutmottagningen. Vikten av stöd och bemötande ansågs vara viktiga för föräldrarna samt att de blir bemötta med respekt och empati från vårdpersonal. De önskar att möten ska ske på ett barnanpassat sätt. Föräldrarna upplever även att vårdpersonalen har tidsbrist vilket hindrar den familjecentrerade omvårdnaden. / Background: Parents’ encounter with healthcare workers plays a big part in the care of children. To promote good care and treatment methods like family-centred care are used. However, nurses asked about family-centred care explained it is not used well despite being considered important. By improving our understanding of parents’ perceptions, we can identify areas of improvement. Purpose: This study aimed to describe parents’ experiences of encounters with healthcare workers during paediatric visits to the emergency department. Method: Literature study following the nine-step model by Polit and Beck (2021), searching CINAHL and PubMed, and using reflexive thematic analysis according to Braun and Clarke (2021). Results: Four themes and twelve subthemes were identified. The themes were Communication and treatment,Emotions and experiences, Effective healthcare and resources, and Environment and proximity. Conclusions: Parents described overwhelming feelings when visiting the emergency department. They emphasised the importance of support and treatment from healthcare workers and to be greeted with respect and empathy. They wish for encounters to be child-appropriate. Parents noted that healthcare workers seemed to experience a lack of time, preventing them from applying family-centred care.

Befolkningen i världen blir allt äldre och fler personer över 60 år drabbas av akuta sjukdomar och riskerar att utveckla skörhet. Den äldre har ofta mer komplexa och större omvårdnadsbehov vilket leder till fler vårdbesök med längre vänte- och vistelsetid. Därutöver har den äldre ofta minskade fysiologiska funktioner, reservkapaciteter samt högre risk att drabbas av komplikationer, varför omhändertagandet av denna patientgrupp kräver ökad kunskap. Då tidigare forskning främst har fokuserat på den äldre personens patientupplevelse inom slutenvården behövs mer kunskap inom akutvården. Syftet med detta arbete var att undersöka den äldre personens upplevelse av vården på akutmottagningen. Studien hade en induktiv ansats med en allmän litteraturöversikt som design. Sökningarna utfördes i PubMed och Cinahl med hjälp av MeSH-termer och CINAHL Subject Headings samt fritextsökningar. Inklusionskriterierna var kvalitativa artiklar samt personer över 60 år som hade besökt akutmottagningen. Exklusionskriterierna var artiklar som saknade etiska överväganden, översiktsartiklar och artiklar som berörde andra perspektiv. Resultatet presenterades med tre kategorier och sex underkategorier. Kategorierna var; Att vara på akutmottagningen, Att vårdas på akutmottagningen och Att bli utskriven från akutmottagningen. I de 15 artiklar som inkluderades i studien framkom bland annat att den äldre personen kände sig sårbar och bortglömd på akutmottagningen. Hälso- och sjukvårdspersonal som lät den äldre personen vara delaktig i det akuta omhändertagandet kunde generera en positiv upplevelse. Kommunikation och information ansågs vara nyckelkomponenter för att mötet skulle bli så bra som möjligt. En hektisk vårdmiljö med långa väntetider upplevdes negativt samtidigt som upplevelsen blev mer positiv ju mer den äldre blev delaktig i utskrivningsprocessen. Studien identifierade faktorer som kunde påverka den äldres upplevelse av akutmottagningen. Detta innefattade hälso- och sjukvårdspersonalens bemötande, kommunikation och information, delaktighet och en anpassad vårdmiljö. Dessa faktorer bör tas i beaktande vid omvårdnaden och omhändertagandet av den äldre personen på akutmottagningen. / The global population is getting older, with an increasing number of individuals over 60 years are facing acute illnesses and the risk of developing frailty. Elderly individuals often exhibit more complex care needs, leading to extended healthcare visits and longer waiting time. Due to diminished physiological functions and higher complication risks, providing care for this demographic demands enhanced knowledge. While prior research primarily focused on inpatient experiences, there's a crucial need for more insights into emergency care. The aim of this study was to investigate the older person's experience of care in the emergency department. This study has an inductive approach with a literature review design. The searches were performed in PubMed and Cinahl utilized MeSH terms and CINAHL Subject Headings, alongside free-text searches. Inclusion criteria involved individuals over 60 who visited emergency departments and qualitative articles. Exclusion criteria encompassed articles lacking ethical considerations, review articles and other perspectives than the older person. Results were categorized into three categories and six subcategories: The categories are; To be in the emergency department, To be treated in the emergency department and To be discharged from the emergency department. Among the 15 articles included, findings revealed that older people often felt vulnerable and overlooked in emergency departments. Positive experiences were generated when healthcare professionals involved them in acute care decisions. Effective communication and information sharing were deemed critical components for a positive encounter. A bustling care environment with prolonged waiting times was perceived negatively, whereas increased involvement in the discharge process improved the overall experience. The study identified key factors influencing the older people’s experience in emergency departments, emphasizing the significance of healthcare professionals' approach, communication, involvement, and an adapted care environment. These factors should be considered in providing optimal care for older individuals in emergency settings.

Bakgrund: Arbetet för sjuksköterskor på akutmottagningen har beskrivits som emotionellt påfrestande och fyllt av stress. Detta leder till att sjuksköterskor behöver utveckla strategier för att hantera stressen. De som inte utvecklar effektiva åtgärder riskerar att drabbas av utbrändhet eller lämnar yrket. En av de faktorer som rapporterats orsaka stress är patienters dödsfall. Syfte: Den här litteraturöversiktens syfte var att beskriva sjuksköterskors upplevelser av dödsfall på akutmottagningen.  Metod: För den här litteraturöversikten användes en induktiv ansats och inkluderade artiklar av kvalitativ metod. Totalt analyserades 12 artiklar med hjälp av Fribergs analysmodell. Resultat: Resultatet sammanställdes i två teman och sju subteman. Det framgick att sjuksköterskor upplevde dödsfall som emotionellt påfrestande speciellt när yngre patienter oväntat gick bort och att de saknade stöd för att hantera den påfrestningen. De upplevde också otillräcklighet i mötet med döende patienter och deras anhöriga, samt att akutmottagningen inte var en bra plats att dö på. Slutsats: Sjuksköterskor upplevde en brist på utbildning och kunskap kring att bemöta döende personer och deras anhöriga, och att miljön på akutmottagningen hindrade dem från att ge den omvårdnad som behövdes. På grund av den emotionella påverkan som dödsfall har på sjuksköterskor behöver de strukturerade sätt för att hantera den stress de upplever. / Background: The work of emergency department nurses has been described as emotionally demanding and stressful. As a result, nurses need to develop strategies to cope with stress. Those who do not develop effective measures are at risk of burnout or leaving the profession. One of the factors reported to cause stress is death of patients. Aim: The aim of this literature review was to describe nurses' experiences of death in the emergency department. Method: For this literature review, an inductive approach was used and included articles of qualitative method. A total of 12 articles were analysed using Friberg's analysis model. Results: The results were described in two themes and seven sub-themes. It appeared that nurses experienced death as emotionally stressful, especially when younger patients died unexpectedly and that they lacked support to deal with this stress. They also experienced inadequacy in the meeting with dying patients and their relatives and that the emergency department was not a good place to die in. Conclusion: Nurses experienced a lack of training and knowledge in dealing with dying people and their families, felt that the environment in the ED prevented them from providing the necessary care. Because of the emotional impact that death has on nurses, they need structured ways to deal with the stress they experience.