The Ottawa Hospital cancels hundreds of elective surgeries every year due to a lack of beds, and has an average weekday occupancy rate above 100%. Our approach to addressing these issues, by way of informing administrators of resource needs, was to model the flow of patients coming and going from the hospital. We used administrative data from the Ottawa Hospital to build a time-series model of emergency department admissions, and studied models that would predict next-day discharge of patients currently taking up hospital beds. In the latter, we considered population-averaged models for groups of patients based on their primary medical condition, as well as subject-specific models. We included the random effects from subject-specific variation to improve on predictive accuracy over the population- averaged approach. The result was a model that provided more realistic probabilities of discharge, and stable predictive accuracy over patient length of stay.

Avoidable use of the Emergency Departments (EDs) constitutes a significant public health problem, which has health, economic and ethical implications. The factors that affect avoidable use of the EDs are complex and poorly understood. The goal of this dissertation was to examine the role of medical home in avoidable pediatric ED visits, assess the impact of Medicaid policy on ED visits for dental problems and assess the factors affecting follow-up dental care after a dental ED visit. Iowa Household Health Survey data was used for the first study, which included a sample of families with at least one child residing in Iowa. It was found that 68% of parents who took their child to an ED in the previous year thought the ED visit could have been avoided if primary care was available to them. Having a medical home was not found to be associated with pediatric ED visits; however, food insecurity was significantly associated. Parents of children with public insurance, those who were not referred by a healthcare provider and those who reported difficulty in getting routine care appointments were more likely to report an avoidable ED visit by their child. The second study examined a policy change in California where Medicaid eliminated its comprehensive adult dental coverage on July 1, 2009. State Emergency Department Database were obtained from Agency for Healthcare Research and Quality for California for 2006 through 2011. Interrupted time series, a quasi-experimental approach of was used to examine the impact of the policy change on rate of dental ED visits by Medicaid enrolled adults. Segmented linear regression revealed that policy change led to an immediate significant increase in the rate of dental ED visits. The policy had a differential impact on various subgroups based on age, race-ethnicity and residential location. The annual costs associated with dental ED visits made by Medicaid adults also increase 68%. Survival analytic approach was used in the final study to examine the patterns of dental care following a dental ED visit by Medicaid enrolled adults in Iowa. Medicaid claims and enrollment data were used to identify adults with an index dental ED visit in 2011, and then each subject was followed for up to 6 months. About 52% of all adults who satisfied the study inclusion criteria, had a follow up dental visit within 6 months of the index dental ED visit. Cox regression model revealed that adults who had visited a dentist in the year prior to the ED visit had greater hazards of having an early dental follow up after the ED visit. Having repeated dental ED visits was found to have a dose-response relationship to follow-up time to dentist visit, with those having 1 repeat ED visit having 53% hazards and those with 2 or more repeat ED visits having 34% hazards of having a follow-up dentist visit, compared to those with no repeat ED visits. Collectively, the results from this dissertation provide important insights in understanding the complex problem of avoidable ED visits. Factors such as food insecurity and medical home need to be further investigated in their association with avoidable ED visits. State Medicaid policy plays an important role and limiting Medicaid adult dental coverage may lead to an increased reliance of the affected population on EDs for dental care. However, EDs do not provide any definitive dental care, and our results indicate that almost half of the adults with dental ED visit do not have a follow-up dentist visit in the next 6 months.

El presente estudio se llevó a cabo en el departamento de emergencia y cuidados críticos del Hospital Nacional Hipólito Unánue, hospital de tercer nivel de atención. El motivo del estudio se basó en realizar una mejora en los procesos buscando una excelencia operativa que permita reducir los tiempos de espera, mejorar el manejo de información y eliminar actividades que no generen valor en los procedimientos. Para llevar a cabo el proyecto se utilizó diversas herramientas de la técnica Lean HealthCare con la finalidad de eliminar las ineficiencias y lograr que todo el trabajo realizado proporcione valor y cumpla con las necesidades de los pacientes. En primer lugar, se realizó un estudio de las técnicas lean y de la situación actual de la institución en estudio. Posteriormente se realizó un diagnóstico mediante una simulación de la situación actual y analizar las causas raíces de los problemas que se suscitan en el centro de salud. Seguido de ello se evaluó la situación actual del área e identificar los puntos de mejora buscando brindar una atención en el menor tiempo posible. Finalmente se realizaron mejoras, ya que se redujeron los tiempos de atención y se mejoraron los procedimientos de atención que se realizan en el departamento de emergencia y cuidados críticos más eficiente y eficaz. / The present study was carried out in the emergency and critical care department of the Hipolito Unanue National Hospital, a third-level care hospital. The reason for the study was based on making an improvement in the processes seeking operational excellence that allows to reduce waiting times, improve the handling of information and eliminate activities that do not generate value in the procedures. To carry out the project, various tools of the Lean HealthCare technique were used in order to eliminate inefficiencies and ensure that all the work done provides greater value and meets the needs of patients. In the first place, a study of the lean techniques and the situation of the institution under study was carried out. Subsequently, a diagnosis was made through a simulation and the root causes of the problems that arise in the health center were analyzed. Following this, the points of improvement were evaluated and identified, seeking to provide attention in the shortest possible time. Finally, improvements were made, since the attention times were reduced and the care procedures performed in the emergency department and critical care were improved. / Trabajo de Suficiencia Profesional

Bakgrund: I akutmottagningen kan det vara ett högre arbetstempo än på andraavdelningar och det kan vara svårare att skapa en djupare kontakt med patienterna pågrund av en stressande miljö. Tidigare forskning påvisade sjuksköterskans roll och desskomplexitet i relations-skapandet med patienten. Syfte: Syftet var att beskriva aspekter ibemötande mellan sjuksköterska och patient inom akutmottagningen, utifrån patientensperspektiv. Metod: En beskrivande litteraturstudie uppbyggd av 11 artiklar medkvalitativa och kvantitativa ansatser. Huvudresultat: Det framkom att sjuksköterskanskommunikation och kompetens var viktiga aspekter av sjuksköterskans bemötande enligtpatienternas upplevelser. I huvudtemat kommunikation ingick underkategorierna verbalkommunikation; icke verbal kommunikation och i huvudtemat kompetens ingickprofessionalitet och engagemang; patientbehov som underkategorier. Slutsats: Vid etthögre arbetstempo kan det försvåra för sjuksköterskans förmåga att bemöta patienternaefter deras individuella behov och nivå. Enligt patienternas upplevelser ärsjuksköterskans kompetens och kommunikationsförmåga betydelsefulla aspekter isjuksköterskans omvårdnadsarbete. Denna kunskap och förmåga kan leda till enminskning av patientens lidande, gynna personalens arbetssätt och höja vårdkvaliteten. / Background: In the emergency department, it can be a higher work pace than in otherwards, which could be more problematic to create a deeper contact with patients due tothe stressful environment. Previous research demonstrated the nurse's role and itscomplexity in relationship building with the patient. Aim: The aim was to describeaspects of treatment between nurse and patient from the patient's perspective in theemergency department. Method: A descriptive literature review based on 11 articleswith qualitative and quantitative approaches. Main results: It emerged that the nurse'scommunication and competence were significant aspects of the nurse's treatmentaccording to the patients' experiences. The theme of communication containedsubcategories verbal- and nonverbal. The second theme was competence with thesubcategories of professionalism and commitment; patient needs. Conclusion: At ahigher work pace, it can be difficult for the nurse to treat patients according to theirindividual needs and levels. The nurse's competence and communication skills weresignificant aspects in their perception of treatment according to the patient's experience.It can reduce

Bakgrund: Missfall är en vanlig graviditetskomplikation som kan erfordra tillsyn från vården, ofta genom besök på en akutmottagning. Upptäckt av missfall är vanligast mellan graviditetsvecka 9 till 11 och orsakar ofta känslor av sorg och förlust hos kvinnan. Syfte: Syftet var att beskriva kvinnors upplevelser av omvårdnad på akutmottagningen i samband med missfall eller misstänkt missfall. Metod: En allmän litteraturstudie med induktiv ansats genomfördes. Tio vetenskapliga artiklar med kvalitativ ansats bearbetades i en innehållsanalys. Resultat: Innehållsanalysen resulterade i tre huvudkategorier: Behov av information i samband med missfall, Betydelsen av bemötande och emotionellt stöd samt Miljön på akutmottagningen – en utmaning. Flera kvinnor upplevde bristande information, bemötande och emotionellt stöd. Att vänta på akutmottagningen upplevde många som frustrerande. Brist i avskildhet och tidsbrist hos vårdpersonal framkom. Konklusion: Kvinnor upplevde genomgående bristande omvårdnad även om positiva upplevelser förekom i vissa fall. Sjuksköterskor kan åtgärda bristerna genom att ge adekvat information, bra bemötande och emotionellt stöd. / Background: Miscarriage is a common pregnancy complication which might require healthcare supervision, often by a visit to the emergency department (ED). Discovery of miscarriage is most common between the 9th and 11th week of pregnancy and often causes feelings of grief and loss among women. Aim: The aim was to describe women´s experiences of care at the ED while having a miscarriage or suspected miscarriage. Method: A general literature study with an inductive approach was implemented. Ten scientific articles with a qualitative approach were analyzed through content analysis. Results: The content analysis presents three maincategories: The need of information while experiencing a miscarriage, The importance of the encounter of healthcare professionals and emotional support and The environment at the emergency department – a challenge. Several women experienced a shortage of information, lacks in the encounter of healthcare professionals and an absence of emotional support. Many experienced the waitingtime at the ED as frustrating. Lack of privacy and time among healthcare staff was described as a problem. Conclusion: Over all women experienced lack of care even though positive experiences occurred in some cases. Nurses might remedy these shortages by giving accurate information, a proper encounter and emotional support.

Hospital systems in the United States are facing a dilemma regarding capacity management in the emergency department (ED) and the inpatient care setting. The average wait time in EDs across the United States exceeds 98 minutes, which is also the point at which patients begin to abandon healthcare treatment. The purpose of this quantitative study was to examine the use of queueing theory in capacity management on length-of-stay (LOS) rates, left-without-being-seen (LWBS) rates, and boarding rates in the ED and inpatient setting. The boarding rates represent the rate in which patients were roomed in the ED but required inpatient care. This study assessed the relationships between capacity management using queueing theory and a reduction in the aforementioned rates compared to traditional processes across systems within the continental United States. A linear regression analysis with a confidence interval 95% paired with an independent sample t test was used to analyze the secondary datasets. A sample size of approximately 33,000 patients was tested in the areas of LOS, LWBS, and boarding. The results of the analysis determined that access was improved in the ED and inpatient setting when queueing theory was deployed within the hospital system compared to traditional processes for managing capacity within the system. Queuing theory used for capacity management resulted in lower LOS, LWBS, and boarding rates. The implications of this study for positive social change include the opportunity to provide greater access to care for the population as a whole, and better health outcomes for the promotion of population health.

Bakgrund: Patientbesöken på svenska akutmottagningar har minskat men väntetider har ökat. Systemet triage används av sjuksköterskor för att prioritera patienter med utifrån deras anamnes och symtom. En god vårdmiljö, regelbunden kommunikation, information, ökad delaktighet och personcentrerad vård kan minska uppkomsten av vårdlidande för patienter som sökt vård på svenska akutmottagningar. Syftet: Syftet var att belysa hur det är att vara patient under väntetiden på svensk akutmottagning. Metod: Studien är en litteraturöversikt som är baserad på tio vetenskapliga artiklar med kvalitativ metod. Resultat: Tre huvudkategorier mötet med sjuksköterskan, faktorer som påverkar upplevelsen, konsekvenser av bristande vård. Sex underkategorier positiva erfarenheter, negativaerfarenheter, vårdmiljöns inverkan, grundläggande behov, utsatthet och sårbarhet samt situationen accepteras. Diskussion: I diskussionen redogör författarna patientersupplevelser från akutmottagningen. Det diskuterades kring tre begrepp personcentrerad vård, vårdlidande och delaktighet. Konklusion: Det framkom att när grundläggande behov blev tillgodosedda, information gavs och när sjuksköterskan gav bekräftelse kunde delaktigheten öka och vårdlidande förhindras. / Background: Patient visits at Swedish emergency departments have decreased, but waitingtimes has increased. The triage system is used by nurses to prioritize patients based on their health background and symptoms. A good care environment, regular communication, information, increased participation and person-centered care can reduce the incidence of caregiving for patients who have sought care at Swedish emergency departments. Aim: The aim of this study was to illustrate what it is like to be a patient under waiting time at a Swedish emergency department. Method: This study is a literature review based on ten scientific articles with a qualitative method. Results: Three main categories of meeting with the nurse, factors affecting the experience, consequences of inadequate care. Six subcategories of positive experiences, negative experiences, the impact of the care environment, basic needs, exposure and vulnerability and situation is accepted. Discussion: In the discussion, the authors emphasize patients’ experiences from the emergency department. It was discussed around three concepts person-centered care, caregiving and participation. Conclusion: It emerged that when basic needs were met, information was provided and when the nurse gave confirmation, participation increased, and care sufferers could be prevented.

Bakgrund: Sköra äldre definieras som en äldre person med ökad sårbarhet och därmed förhöjd risk att utsättas för vårdskador i hälso- och sjukvården. Det är viktigt att känna till begreppet skörhet och att kunna identifiera skörhet hos äldre personer för att ge den äldre patienten en patientsäker vård samt minska risk för vårdskada. Var tionde äldre patienten får vänta längre än sju timmar innan de kan skrivas in på en avdelning eller lämna en akutmottagning. Sjuksköterskor anser att det är svårt att göra rätt bedömning och anpassa vården efter en skör äldre, samt att prioritera rätt utefter vårdbehov. Syfte: Syftet med denna litteraturöversikt är att studera användbarheten av bedömningsinstrument för att sjuksköterskan ska kunna identifiera sköra äldre som söker vård på en akutmottagning samt sjuksköterskors upplevelse till att använda bedömningsinstrument. Metod: Studien är en litteraturöversikt där resultatet är baserat på 15 vetenskapliga artiklar. Artikelsökningarna genomfördes i databaserna Pubmed och Cinahl. Resultat: Tio bedömningsinstrumenten beskrivs i studiens resultat. Resultaten presenteras i två huvudkategorier; vilka bedömningsinstrument beskrivs och vad är sjuksköterskornas upplevelse till att använda bedömningsinstrumenten. Bedömningsinstrumenten Clinical frailty scale [CFS], och FRail Elderly Support researcH group [FRESH] verkar vara snabba och effektiva för att bedöma skörhet hos de äldre på en akutmottagning. Sjuksköterskorna har en positiv inställning till att använda ett bedömningsinstrument, men upplever att det är tidsbrist och därmed upplever sjuksköterskor svårigheter att använda ett bedömningsinstrument. Slutsats: Ett alternativ för att avlasta sjuksköterskor på en akutmottagning och främja en patientsäkervård kan vara att ha en specialistsjuksköterska inom geriatrik som fokuserar på själva bedömningen av sköra äldre. Sköra äldre patienter bör markeras som sköra i journalsystemet för att lättare och snabbare få en mer anpassad och säkrare vård. Till följd av en snabb bedömning av skörhet kan sjuksköterskorna på en akutmottagning vidta omvårdnadsåtgärder direkt för att förebygga och förhindra att en vårdskada ska uppstå. / Background: Frail elderly are defined as older people with increased vulnerability with a higher possibility of getting injured while receiving healthcare. It is important to know the concept of frailty and to be able to identify frailty in older persons, in order to provide patients with safe care and reduce the risk of injury. One out of ten patients have to wait for 7 hours and 18 minutes before they get offered care or can leave the emergency department. Healthcare personnel admits it is hard to make an assessment, adjust healthcare and prioritize the care towards frail older people. Aim: The aim of this literature review is to study the usefulness of assessment tools for the nurse to be able to identify frailty older who seek care at an emergency department and the nurse's experience of using assessment tools. Method: The study is a literature review and the results are based upon 15 compiled scientific articles. The PubMed and Cinahl databases were used to search for articles. Results: Ten different assessment instruments are described in this study. Two main questions were asked. These were: Which assessment tool are there to help the nurses to identify frail older in an emergency department? What is the nurses experience of using these assessment tools? Clinical frailty scale [CFS], och FRail Elderly Support researcH group [FRESH] seems to be quick and effective in assessing the frailty of the older at an emergency department. The nurses have a positive attitude towards using an assessment instrument, But they feel a shortage of time and therefore nurses experience difficulties in using an assessment instrument. Conclusion: An alternative to relieving nurses at an emergency department and promoting patient care may be to have a specialist nurse in geriatrics that focuses on the assessment of frail older people. Frail older patients should be marked as frail in the medical record system to more easily and more quickly receive a more customized and safer care. As a result of a rapid assessment of fraility, the nurses at an emergency department can take nursing measures directly to prevent and prevent a medical injury from occurring.

Sammanfattning Bakgrund: Hot och våld mot vårdpersonal är ett aktuellt ämne och ett globalt växande problem i dagens samhälle. Sjuksköterskor som arbetar på akutmottagningar anses vara en av professionerna som är i störst risk för att utsättas för hot och våld.   Syfte: Syftet var att beskriva sjuksköterskors upplevelse av hot och våld på akutmottagningar. Metod: Litteraturöversikten är baserad på tio vetenskapliga artiklar. Samtliga tio artiklar är av kvalitativ karaktär. De vetenskapliga artiklarna som inkluderades i resultatet, är publicerade mellan åren 2009–2018. För artikelsökningen användes databaserna CINAHL och PubMed. Resultat: Resultatet gav sammanlagt tre huvudteman och fem subteman. Huvudtemat ”Upplevelser av olika riskfaktorer” resulterade i subteman; ”Sjuksköterskan som en sårbar profession”, ”Patienters beteende” och ”Arbetsgivarens begränsade möjligheter”. Huvudtemat ”Upplevelser av negativa effekter på arbetsplatsen” resulterade i subteman; ”Sjuksköterskans arbetsmiljö” och ”Sjuksköterskans yrkesutövande”. Resultatets sista huvudtema blev ”Upplevelser av påverkan på den egna hälsan”. Slutsats: Litteraturöversikten resulterade i en slutsats att sjuksköterskor som drabbats av hot och våld i sitt arbete på akutmottagningarna påverkas privat, men även i sitt arbetsliv. Att hot och våld har en påverkan på sjuksköterskors psykiska- och fysiska mående, samt att det även kan framkalla många olika känslor. / Summary Background: Threats and violence against healthcare professionals is a global issue and a growing problem in today’s society. Nurses who work in the emergency department are considered to be one of the professionals that is at most risk of being exposed to threats and violence. Aim: The aim of this literature review was to describe nurses’ experience of threats and violence at the emergency department. Method: The literature review  was compiled of ten scientific articles that were conducted using a qualitative method. The scientific articles that were included in the result were published between the years of 2009 – 2018. For the article search, the databases CINAHL and PubMed were used. Results: The data analysis resulted in three main categories and five sub-themes. The main theme “Experiences of different risk factors” resulted in subthemes; “The nurse as a vulnerable profession”, “Patient behavior” and “Employer’s limited opportunities”. The main theme “Experiences of negative effects in the workplace” resulted in subthemes; “Nurse’s working environment” and “The nurse’s professional practice”. The final main theme of the result was “Experiences of impact on one’s own health”. Conclusion: The conclusion is that nurses affected by threats and violence in their work at emergency department affected the nurses privately, but also in their working lives. That threats and violence have an impact on the nurses mentally and physically, and that it also evokes many different emotions.

Les chutes à domicile sont un signe précurseur de la perte d’autonomie et représentent un problème majeur de santé publique. La chute implique de multiples facteurs déterminant le risque de chute. Une meilleure connaissance des facteurs de risques de la chute est importante afin de prévenir les chutes ainsi que l’entrée en dépendance chez la personne âgée. Parmi ces facteurs de risques les facteurs biologiques sont peu étudiés. Mieux connaître ces facteurs biologiques permettrait de mieux orienter le diagnostic étiologique de la chute et donc de cibler les actions préventives personnalisées et de définir par des interventions environnementales (ex : l’activité physique, conseils nutritionnels) ou médicales, de prévenir le risque de chute et la perte d’autonomie qu’elle induit. L’hyponatrémie est le désordre électrolytique le plus fréquent rencontré en pratique gériatrique. Elle est définie par une concentration en Na dans le sérum inférieure à 136 mmol/L. L’hyponatrémie peut être divisée en 3 paliers : l’hyponatrémie chronique légère l’hyponatrémie modérée et l’hyponatrémie sévère. De récentes études ont montré que l’hyponatrémie chronique légère peut présenter chez les patients des signes cliniques significatifs et pourrait être associée à une altération des fonctions cognitives, à des troubles de la marche voire de fracture. Qu’elle est la prévalence de l’hyponatrémie chronique légère chez les patients admis à l’unité MUPA ? Qu’elle est l’association entre l’hyponatrémie chronique légère et la chute dans notre population ? La prévalence de l’hyponatrémie chronique légère est particulièrement élevée à l’unité MUPA. les patients admis à l’unité MUPA avec une hyponatrémie chronique légère à la prise de sang effectuée à l’arrivée dans l’unité ont un plus fort risque de chute grave. L’hyponatrémie chronique légère peut-être considérée comme un facteur de risque de la chute grave chez le sujet âgé. / Falls are a precursor to the loss of autonomy and represent a major public health problem. Falls involve multiple factors determining the risk of falling. A better knowledge of the risk factors of falls is important in order to prevent falls as well as loss of autonomy in the elderly. Among these risk factors, biological factors are poorly studied. Better knowing these biological factors would better guide the etiological diagnosis of the fall and therefore target personalized preventive actions and define environmental interventions (physical activity, nutritional counseling) or medical, to prevent the risk of falling and the loss of autonomy. Hyponatremia is the most common electrolyte disorder in geriatric practice. It is defined by a serum Na concentration of less than 136 mmol/L. Hyponatremia can be divided into 3 stages: mild chronic hyponatremia, moderate hyponatremia, and severe hyponatremia. Recent studies have shown that mild chronic hyponatremia may present significant clinical signs in patients and may be associated with impaired cognitive functions, gait disturbances and even fractures. What is the prevalence of mild chronic hyponatremia in patients admitted to MUPA unit? What is the association between mild chronic hyponatremia and falls in our population? Prevalence of mild chronic hyponatremia is particularly high at MUPA unit. Patients admitted to MUPA unit with mild chronic hyponatremia at the first blood test performed on arrival have a higher risk of serious falls. Mild chronic hyponatremia may be considered as a risk factor for serious falls in the elderly