Bakgrund: Antalet omkomna i katastrofer har ökat de senaste 20 åren. 2,6 miljardermänniskor drabbades av katastrofer under 2010-talet. Samhället förändras vilket leder tillökad risk för katastrofer. WHO rapporterade år 2022 en sårbarhet i sjukvårdssystemet globalt,sjukhus och dess personal är dåligt rustade för katastrofer. Enligt ICN och WHO ärsjuksköterskor ofta i frontlinjen när en katastrof inträffar. Då det sällan sker behöversjuksköterskor tydliga rutiner för att veta hur de ska arbeta i samband med en katastrof.Sjuksköterskor behöver praktiska, medicinska och organisatoriska kunskaper för att hanteraen katastrof. Syfte: Syftet var att beskriva sjuksköterskors upplevelse av handlingsberedskap inför enkatastrof på en akutmottagning. Metod: En integrativ litteraturstudie enligt Whittemore och Knafl (2005). Artiklar eftersökta iCinahl, PsycINFO och PubMed. Litteraturstudien baseras på 15 artiklar. Resultat: Resultatet utgörs av två teman och sex kategorier. Positiv påverkan påhandlingsberedskapen med tillhörande kategorier; Högre utbildning och erfarenhet påverkarhandlingsberedskapen positivt, Lojalitet med kollegor och pliktkänsla samt Tillit och tryggheti arbetsgruppen och till ledningen. Negativ påverkan på handlingsberedskapen medtillhörande kategorier; Oförberedelse att axla ledarskapet, Nonchalans för katastrofplanersamt Låg kunskap, låg handlingsberedskap och rädsla för att vårda vissa patientgrupper. Slutsats: Erfarenhet och utbildning ger en ökad handlingsberedskap hos sjuksköterskor införkatastrofer. Det finns områden med kunskapsluckor, där kunskap och kompetens behöverförbättras för att öka handlingsberedskapen och i slutändan förbättra kvaliteten på vården.Trots kunskapsluckorna och osäkerheten kring olika arbetsuppgifter finns en vilja blandsjuksköterskor att delta när en katastrof inträffar. / Background: The number of casualties in disasters has increased in the last 20 years. Duringthe 2010’s 2,6 billion people were affected by disasters. Society is changing which causes anincreased risk for disasters. In 2022 WHO reported a vulnerability in the healthcare systemworldwide, hospitals and their staff have low preparedness for disasters. According to ICNand WHO, nurses are often on the frontline when a disaster occurs. As disasters rarely occurs,nurses need obvious routines on how to work when a disaster occurs. Nurses need practical,medical and organizational skills to manage a disaster. Aim: The aim was to describe nurses' experience of preparedness when a disaster occurs in anemergency department. Method: An integrative literature review according to Whittemore and Knafl (2005). Articlessearched in Cinahl, PsycINFO and PubMed. The literature review is based on 15 articles. Results: The result consists of two themes and six categories. Positive impact onpreparedness with associated categories; Higher education and experience have a positiveeffect on preparedness, Loyalty with colleagues and sense of duty and Trust and safety in thework group and to management. Negative impact on preparedness with associated categories;Unpreparedness to assume leadership, Nonchalance for disaster plans and Low knowledge,low preparedness and fear of caring for certain patient groups. Conclusion: Experience and education provide increased preparedness when a disasteroccurs. There are knowledge gaps, where knowledge and competence need to be improved toincrease preparedness and eventually lead to improved quality of care. Despite the gaps inknowledge and the uncertainty about various tasks, there is a willingness among nurses toparticipate when a disaster occurs.

Master of Science / Department of Industrial & Manufacturing Systems Engineering / Malgorzata J. Rys / Emergency department (ED) overcrowding is a nationwide problem affecting the safety and preparedness of our health care system. Many hospital EDs face significant short and intense surges in demand on a daily basis. However, the surge in demand during disaster event is not short and intense, but it is a sustained one. In order to meet this sudden surge as defined above, hospital EDs need to be more prepared and efficient to cater to increased volume of demand involving huge uncertainties. This thesis looks at the creation and use of discrete event simulation modeling using ARENA 10.0 software. In this thesis, an attempt is made to show how the different arrival patterns and time durations for which victims keep arriving affect the EDs ability to treat the patients. It is shown, how the model can be used to estimate additional resources that would be required to accommodate additional patients within the ED. Various shapes of arrival distributions were tested for different time durations. It was found that the arrival distribution with parameters (3, 4), (3, 3), (4, 2) and (2, 4) did not challenge the institutional capacity. In other words, the hospital was able to treat all the patients without compromising the quality of care up to 24 hours. However, distribution with parameter (3, 2), (2, 2), (3, 1), (1, 2), (2, 3), (2, 1), (1, 4), (1, 3), (1, 1) and (0.5, 2) did affect the system performance. Under these distributions, there was at least one patient who was either dead, LWBS or diverted. This indicates the immediacy with which victims arriving under these distributions overwhelmed the limited resources Our aim was to study, how many more resources would the ED need in order to have zero critical expire, zero Left without Being Seen (LWBS) and zero patients diverted. Arrival distribution (1, 2) was randomly selected to study this objective and it was found that for a 24 hours of simulation run time, an additional of two full trauma resources were required in order to have zero critical expire in trauma rooms area and additional of five ED beds and three nurses were required in treatment area for patients with moderate severity to have zero LWBS. With these additional resources, the ED was also able to treat all the non disaster related patients thereby having zero patients diverted. The same procedure can be used to determine the number of additional resources ED would require to treat all the victims arriving with the rest of the arrival distribution for different time periods. The simulation model built would help the emergency planners to better allocate and utilize the limited ED resources in order to treat maximum possible patients. It also helps estimate the number of additional resources that would be required in a particular scenario.

The purpose of this qualitative study was to explore and describe the extent to which registered nurses’ practice was affected by emergency department overcrowding. Participants were recruited from a tertiary hospital by using the purpose sampling method. Data collection was done using a semi-structured interview guide. Individual interviews were conducted with eight registered nurses working in the paediatric emergency department. Data analysis was conducted using thematic content analysis and Yin’s (2003:178) five-phase cycle. The study findings revealed that the lack of professional nurse leadership and the difficult existing relationship with the physicians were obstacles that had to be obviated if the paediatric ED were to function optimally and best practice were to be achieved. It was revealed that a problematic issue in the setting was that the most critical decisions on allocating where patients should be treated were made by physicians who have more authority than nurses. It was recommended that the ED need to be clearly defined in the policies as an outpatient, emergency care or as an episodic patient care area as “Admission” can mean admission to the ED or admission as an inpatient/boarded patient. / Health Studies / M.A. (Health Studies)

Syfte: Syftet med studien var att beskriva sjuksköterskors erfarenheter av omhändertagandet av akut sjuka barn på en akutmottagning. Bakgrund: Att ta emot akut sjuka barn är en faktor som orsakar stress för sjuksköterskor som arbetar på akutmottagningar. Det råder brist på specialistutbildade sjuksköterskor med inriktning barn- och ungdom i Sverige. Enligt Nordiskt nätverk för barn och ungas rätt och behov inom hälso- och sjukvård (NOBAB) ska alla barn tas om hand av sjuksköterskor som har erfarenhet av och utbildning i barnomhändertagande. Att beskriva sjuksköterskors erfarenheter i samband med omhändertagandet av akut sjuka barn kan ha betydelse i framtiden då rutiner/riktlinjer, utbildningar, arbetssätt, kompetensstegar utformas och även för att tillgodose sjuksköterskans välbefinnande. Design: En kvalitativ design valdes för att besvara syftet. Metod: Tolv sjuksköterskor från en akutmottagning intervjuades under 2016. Intervjuerna analyserades genom kvalitativ innehållsanalys. Resultat: Sjuksköterskans erfarenheter av att vårda akut sjuka barn på en akutmottagning beskrevs i fyra kategorier: vård av barn är annorlunda mot vård av vuxna, förberett teamarbete med god struktur underlättar, oförberedd och ovan personal försvårar och intresserad och kunnig för att arbeta med barn är fördelaktigt. Slutsats: För att arbeta med akut sjuka barn på en akutmottagning anser sjuksköterskorna att de behöver ta hand om barn regelbundet och få mer utbildning (praktisk och teoretisk) om barn. När sjuksköterskorna arbetar på ett strukturerat sätt underlättar det omhändertagandet av det akut sjuka barnet. Nyckelord: akut, akutmottagning, barn, erfarenheter, kvalitativ, omvårdnad, sjuksköterskor, utbildning

Bakgrund: Patienter med psykisk sjukdom har en ökad risk för somatiska sjukdomar, något som gör att de ofta är tvungna att söka sig till akutmottagningar där de ofta upplever att de inte blir sedda och inte heller trodda på. Tidigare studier visar på att stigmatisering av patienter med psykisk sjukdom förekommer såväl i samhället som hos vårdpersonal. Miljön på akutmottagningar är ofta stökig och sjuksköterskorna har ofta ont om tid. Syfte: Syftet var att undersöka hur sjuksköterskor i den somatiska akutsjukvården upplever att det är att vårda patienter med psykisk sjukdom. Metod: Forskningsdesignen som valdes var intervjustudie med kvalitativ ansats. Nio sjuksköterskor som jobbat på en akutmottagning i minst ett år intervjuades. Intervjuerna genomfördes på två akutmottagningar. Tematisk analys med induktiv ansats valdes som kvalitativ analysmetod. Resultat: Huvudresultaten av studien sammanfattades i två övergripande teman; den kännande sjuksköterskan och den professionella sjuksköterskan. Följande kategorier kunde placeras in i de två nämnda teman: känslor, fördomar, tid och miljö, bemötande och empati, kunskapsbrist och utbildning samt ansvar. Resultatet visade att sjuksköterskorna på akutmottagningar ofta upplevde känslor som frustration och hopplöshet då de vårdar patienter med psykisk sjukdom. Sjuksköterskorna upplevde att tidsbrist, kunskapsbrist och vårdmiljön på akutmottagningarna var faktorer som försämrade möjligheten till ett bra bemötande och god omvårdnad av patienter med psykisk sjukdom. Slutsats: Studiens resultat visar att sjuksköterskor på akutmottagningar stod inför många utmaningar och vården av patienter med psykisk sjukdom försvårades på grund utav flera faktorer. Dessa faktorer var kunskapsbrist, tidsbrist, stress, fördomar, ansvar samt vårdmiljön. Känslor som sjuksköterskorna ofta upplevde vid vårdandet av patienter med psykisk sjukdom var frustration och hopplöshet. / Background: Patients with mental illness have an increased risk of somatic diseases, which means that they are often forced to turn to emergency departments where they often feel unseen nor believed in. Previous studies show that stigmatization of patients with mental illness is present both in the society and among health professionals. The environment in emergency rooms are often messy and nurses often have little time. Aim: The aim was to examine how nurses in an emergency care experience about caring for patients with mental illness. Method: The research design that were chosen was an interview study with a qualitative approach. Nine nurses who worked in an emergency department for at least a year were interviewed. The interviews were conducted in two emergency departments. Thematic analysis with inductive approach was chosen as qualitative analysis. Results: The main results of the study were summarized in to two main themes; the sentient nurse and the professional nurse. The following categories could be placed into the two mentioned themes; feelings, prejudices, time and environment, attitudes and empathy, lack of knowledge and education, and responsibility. The results showed that nurses in emergency departments often experience feelings of frustration and hopelessness as they care for patients with mental illness. The nurses felt that the lack of time, lack of knowledge and the un-adapted environment in emergency departments were factors that worsened the possibility of good treatment and good nursing care of patients with mental illness. Conclusion: The results of the study show that nurses in emergency departments were facing many challenges and that the care of patients with mental illness was complicated because out of several factors. These factors were such as lack of knowledge, lack of time, stress, responsibility, preconception and the un-adapted environment. Feelings that nurses often experienced in the care of patients with mental illness was frustration and hopelessness.

OBJECTIVES: To determine the pattern and predictors of use of antiplatelet agents and beta-blockers given in the emergency department (ED) to older adults with acute myocardial infarction (AMI) and its effects on in-hospital mortality and length of hospital stay (LOS) and to determine the effect of computerized ED guideline reminders on their utilization. METHODS: A cross-sectional study using the National Hospital Ambulatory Medical Care Survey (NHAMCS) ED data for years 1992 to 2010 was conducted. Patients were included if they had an admission diagnosis of AMI (ICD-9-CM code 410.xx) and were ≥55 years. Survey logistic regression was used to examine whether there was a trend in the use of antiplatelet agents and beta-blockers across the years and to explore the association between various predictor variables, including ED computerized guideline reminders, and their utilization rates. The chi-square test was used to see whether users of these drugs were different from non-users in their rates of in-hospital mortality. Survey linear regression was used to explore the effect of utilization of these drugs on LOS. All the visits were weighted to get national estimates. All of the analyses were carried out with SAS 9.3 statistical package. RESULTS: A total of 1,771 visits (weighted frequency = 6.1 million) were eligible for this study. Both antiplatelet agents and beta-blockers were shown to have a positive trend across the years. Age, sex, chest pain, triage, using an ambulance, and metropolitan region were all found to be significant predictors of either antiplatelet agent or beta-blocker utilization. Use of beta-blockers was associated with lower in-hospital mortality. Neither drug class had an effect on LOS. Finally, patients who were treated in EDs with computerized guideline reminders were twice as likely to get an antiplatelet agent, but this was not seen with beta-blockers. CONCLUSION: This study displayed a positive pattern across the years in the use of antiplatelet agents and beta-blockers given to older AMI patients. It also showed that age, sex, and other important variables were significant predictors of their utilization. The use of beta-blockers yielded lower in-hospital mortality. Finally, the use of ED reminders increased antiplatelet agent utilization.

The Vrinnevi hospital in Norrköping faces a series of changes in conjunction with “Vision 2020”, the emergency ward is no exception. One of the goals that has been set up is to have 80 % of the arriving patients leave the ER within four hours, while having received the proper care. This study maps out the flow of patients through the ER, from arrival to discharge, as well as the process in between. The study also identifies the areas where bottlenecks in the patient flow are likely to appear and describes countermeasures to remedy such situations. In order to achieve this, a simulation model has been created. Facts used in the study are mainly based on previous studies, interviews with employees at the emergency ward, as well as some assumptions based on a theoretical background. Visits to the ER in question have been made, to gain a better understanding of the system that the simulation will illustrate. The study does not contain any deeper economic analysis. The focus is placed on examining whether the proposed changes to the system will affect the patient flow by measuring number of discharged patients within four hours, number of patients who receive a medical assessment within 30 minutes and the number of patients who get to meet a doctor within an hour. Five different scenarios, changing the work process at the ER, based on previous studies attempting to reduce patient throughput, have been created. The scenarios have been analyzed to form an understanding of how they may affect the different efficiency measurements of the emergency ward. The scenarios that have been simulated are: implementation of doctor-assisted triage, implementation on a “Clinical Initiative Nurse” in the waiting room, a reduction of administrative workload for the employees and adding resources to the emergency ward during specific hours of the day. Lastly, a combination scenario containing experiments with three of the most efficient measures has been created in order to achieve a discharge rate of 80 % within four hours. In conclusion, it is evident that all the scenarios have a positive effect on the efficiency measurements and that they all can be implemented so long as there is a positive attitude towards change and, in some cases, economic support.

Bakgrund; Hot och våld förekommer dagligen inom verksamheter där vårdpersonal har nära kontakt med människor. Akutmottagningar tillhör en av de mest utsatta vårdmiljöer för hot och våld mot sjuksköterskor. Livsvärldsteori och viktimologi användes som teoretiska referensramar för att få en uppfattning om hur sjuksköterskor som arbetar på akutmottagning upplever samt påverkas av hot och våld från patienter. Få studier granskar sjuksköterskors egna upplevelser av hot och våld. Syfte; Att belysa hur sjuksköterskor på akutmottagningar upplever hot och våld. Metod; En kvalitativ studie med semistrukturerade intervjuer av 12 yrkesverksamma sjuksköterskor, nio kvinnor och tre män med minst ett års erfarenhet av att arbeta på akutmottagning i Sveriges södra sjukvårdsregion (Skåne, Blekinge, södra Halland och Småland). Resultat; Resultatet presenteras i fem kategorier; definitionen av hot och våld, utsatthet, riskfaktorer, genus samt åtgärder vid hot och våld. Riskfaktorer som ansågs ligga till grund för sjuksköterskors utsatthet var b.la. bristande utbildning och bemanning, otillräckliga säkerhetsåtgärder, ensamarbete samt patientens psykiska eller fysiska tillstånd. Slutsats; Sjuksköterskor på akutmottagningar upplever hot och våld som ett obehag eller rädsla, vilket ger en negativ påverkan i omvårdnadsarbetet och på det psykiska välmåendet. Känslan att ej kunna skydda sig vid hotfulla och våldsamma situationer ger en känsla av maktlöshet både på och utanför arbetsplatsen. För att förbättra arbetsmiljön behövs omfattande internutbildningar i hantering av hot och våld. / Background: Threats and violence are common daily occurrences in any setting where a health care professional comes into contact with people, be it patients or their associates. Emergency departments (EDs) belong to one of the most exposed health care environments in terms of threats and violence against nurses. Lifeworld theory and victimology were used as theoretical frames of reference in order to establish a perception of how nurses working in EDs are exposed to, and affected by threats and violence. Only a handful of published studies examine nurses’ own experiences of threats and violence. Purpose: Was to examine how nurses working within EDs are affected by threats and violence. Method: A qualitative study was conducted based on an analysis of 12 semi-structured interviews with nurses, nine women and three men working in EDs at the time of the interview. For inclusion in the study the nurse needed at least one year experience working in an ED situated in the southern healthcare region of Sweden (including the counties of Skåne, Blekinge, southern Halland and Småland). Results: The results of the study are presented in five main categories: Definition of threats and violence, Exposure, Risk factors, Genus, and Measures taken when faced with threats and violence. Risk factors that may be the origin of their exposure to these experiences are, among others, lack of education and staffing, insufficient safety precautions, working alone and the patient’s physical and/or mental condition. Conclusion: ED nurses experience threats and violence as uncomfortable and fear-eliciting. This has a negative impact on their mental well-being as well as their overall work performance. The sensation of not being able to protect oneself in threatening and violent situations gives a sense of hopelessness and lack of control, both inside and outside of the workplace. To improve the working environment, extensive internal educational efforts are needed to educate ED nurses to cope with threats and violence.

Bakgrund: Triage är numera en viktig del i den moderna sjukvården och innebär prioritering och sortering av patienter. Triagebedömningen utförs oftast av en triagesjuksköterska och då med hjälp av en triageskala som till stor del är avgörande för hur länge patienten bedöms kunna vänta på läkarbedömning. I Sverige är den mest frekvent använda triageskalan RETTS. Dock har studier visat på olikheter i triagenivåer och att triagebedömningen skulle påverkas av triagesjuksköterskans erfarenhet. Syfte: Syftet var att undersöka om det i triagebedömningar på akutmottagning fanns skillnader som berodde på triagesjuksköterskans kliniska erfarenhet sett utifrån triagenivå och ESS-algoritm vid användandet av triageskalan RETTS. Metod: Studien hade en kvantitativ metod och en sekundäranalys av rådata från 2014 genomfördes. Rådatan bestod av enkäter utformade som patientfall vilka hade fyllts i av triagesjuksköterskor från två akutmottagningar i södra Sverige. Dataanalysen gjordes med deskriptiv analys samt med jämförande statistik, Chi2-test. Resultat: Resultaten redovisades utifrån triagenivå, ESS-algoritm samt kommentarer. Skillnaderna mellan de olika erfarenheterna presenterades i tre olika erfarenhetskategorier. I resultatet framkom att det fanns skillnader i triagenivå, ESS-algoritm samt antal kommentarer. Enbart i en analys förekom en signifikant skillnad mellan de olika erfarenhetsgrupperna.   Slutsats: Resultatet visade på skillnader i triagenivåer och ESS-algoritmer men däremot visade inte resultatet i tillräckligt hög utsträckning vad dessa berodde på. Då skillnader i triagebedömningen utgör en patientsäkerhetsrisk samt ökar kostnaden för vården behövs vidare forskning för att försöka ta reda på anledningen till skillnaderna. / Background: Triage has now become an important part of modern health care and involves prioritizing and sorting of patients. It is usually performed by a nurse and with the help of a triage scale. The triage scale is critical for how long the patient can wait to see the doctor. In Sweden the most common triage scale is RETTS. However, studies have shown differences in the triage level and that the triage assessment could be affected by the experience of the triage nurse. Aim: The aim of the study was to investigate if there were any differences in the triage assessment at emergency departments depending on the clinical experience of the triage nurse in reference to the triage level and ESS-algorithm when using the triage scale RETTS. Method: A quantitative study and a secondary analysis was carried out based on data from 2014. The collection of the data has been carried out in two different emergency departments in the South of Sweden through written patient scenarios. Data were analyzed with descriptive statistics and The Chi-square Test. Result: The results was shown in the categories triage level, ESS-algorithm and comments. The differences between experiences was displayed in three different categories. The result showed differences in triage levels, ESS-algorithms and in the number of comments. However, only in one analysis was there a significant difference between the different groups of experiences. Conclusion: The result has shown that there were differences in the triage levels and ESS-algorithms but the result has not sufficiently given an explanation as to why these differences occur. As the differences in the triage assessments constitutes a risk for the patients and increases costs for the health care further research need to be done to try to find out the reason for the differences.

A presente tese apresenta proposições para o desenvolvimento e aplicação de técnicas de mineração de textos, de modo a contribuir para a gestão de operações nas áreas médicas e de negócios. Os objetivos desta tese são: (i) identificar e estruturar técnicas de mineração de texto, de modo a elaborar um método para prever internações de pacientes provenientes de emergências hospitalares, tendo como base somente os registros textuais não estruturados escritos por médicos durante o primeiro encontro médico-paciente; (ii) comparar previsões realizadas pelo método proposto no objetivo (i) com análises médicas realizadas por humanos, de modo a verificar se computadores podem atuar de forma autônoma na tarefa de previsão de internações de pacientes provenientes de emergências hospitalares; e (iii) identificar e estruturar técnicas de mineração de texto, de modo a elaborar um método para prever a satisfação de clientes de companhias aéreas, tendo como base as avaliações escritas e publicadas por passageiros na internet. Os métodos propostos utilizaram diferentes técnicas de mineração de textos, sendo validados por estudos de caso. Em relação à área médica, o método proposto pode realizar previsões em tempo real sobre a necessidade de leitos, ajudando as equipes de gerenciamento de leitos a melhorar os processos de fluxo de pacientes. Além disso, verificou-se que tanto médicos (iniciantes ou experientes), quanto máquina, tiveram desempenhos semelhantes na tarefa de previsão de internação de pacientes. Já em relação à área de negócios, o método proposto permitiu extrair dimensões de satisfação de avaliações online, além dos sentimentos associados a elas, considerando diferentes perfis de passageiros, serviços e períodos de tempo. Desta forma, foi possível prever a recomendação de companhias aéreas baseado nas avaliações escritas por passageiros. / This dissertation presents propositions for the development and application of text mining techniques, in order to contribute to operations management in the medical and business areas. The objectives of this dissertation are: (i) identify and structure text mining techniques, in order to propose a method to predict admissions of patients from hospital emergencies, based only on unstructured textual records written by physicians during the first encounter with patients; (ii) compare predictions made by the method proposed in objective (i) with medical analyses carried out by humans, in order to verify if computers can work autonomously in predicting hospitalizations of patients coming from hospital emergencies; and (iii) identify and structure text mining techniques to develop a method for predicting airline customer satisfaction based on online customer reviews. The proposed methods used different text mining techniques, being validated by case studies. Regarding the medical area, the proposed method was able to perform real-time forecasts about the need for beds, helping bed management teams to improve patient flow processes. In addition, it was found that both physicians (novice or experienced) and machine had similar performances in predicting patient hospitalization. In relation to the business area, the proposed method allowed to extract satisfaction dimensions of online customer reviews, as well as sentiments associated to them, considering different profiles of passengers, services and time periods. It also enabled the prediction of airline recommendation based on online customer reviews.