Many elderly patients visiting the emergency department for minor injuries are not assessed for functional status and experience functional decline 6 months post injury. Identifying such high-risk patients can allow for interventions to prevent or minimize adverse health outcomes including loss of independence. For the purpose of a planned clinical decision rule to identify elderly patients at high risk of functional decline a survey of physicians was conducted. A random sample of 534 Canadian geriatricians, emergency and family physicians was selected with half randomly selected to receive an incentive. A response rate of 57.0% was obtained with 90% of physicians considering a drop in function of at least 2 points on the 28-point OARS ADL scale as clinically significant. A sensitivity of 90% would meet or exceed 90% of physicians' requirements for a clinical decision rule to identify injured seniors at high risk of functional decline 6 months post injury.

Bakgrund: Belastningen på Sveriges akutmottagningar har ökat och antalet sjuksköterskor har minskat. Personalomsättningen är större och fler sjuksköterskor med mindre erfarenhet av yrket anställs. På akutmottagningen möter sjuksköterskan ett brett patientklientel som drabbats av många olika sjukdomar och skador som kan vara livshotande. Bristande erfarenhet kan vara en patientsäkerhetsrisk. Syfte: Syftet med studien är att beskriva sjuksköterskans upplevelser av att vara ny på akutmottagningen, samt undersöka om bristen på erfarenhet kan påverka patienten. Metod: En kvalitativ intervjustudie med beskrivande design valdes utifrån studiens syfte. Semistrukturerande intervjuer genomfördes med tio sjuksköterskor som arbetat i max ett år på en akutmottagning i Region Jönköpings län. En kvalitativ innehållsanalys utfördes på en latent nivå. Resultat: Kategorierna som bildar studiens resultat är vikten av en god introduktion, osäkerhet kring den egna kompetensen, patienten kan påverkas, erfaren personal gav trygghet samt fördelar med att vara ny. Det framkom att stöd var en nyckelfaktor för ett lyckat arbete. Sjuksköterskan ansåg sig inte redo efter introduktionen att arbeta helt självständigt och det efterfrågades mer praktisk träning. Sjuksköterskan hade skapat strategier för att hantera osäkerheten. Bristen på erfarenhet skulle kunna påverka patienten. Slutsats: Det som anses som en mycket viktig faktor för ett väl fungerande arbete är att de mindre erfarna sjuksköterskorna har erfarna kollegor som kan stötta och hjälpa vid behov. Den regiongemensamma introduktionen för sjuksköterskor skulle kunna utvecklas för att även inrikta sig mer specifikt mot akutsjukvård. För att kunna ge det stöd som de mindre erfarna är i behov av krävs en säkrad kompetens hos kollegorna på akutmottagningen. / Background: The burden on Sweden's emergency departments has increased and the number of nurses has decreased. Staff turnover is greater and more nurses with less experience in the profession are employed. At the emergency room, the nurse meets a wide patient clientele who can be affected by many diseases and injuries which can be life threatening. Lack of experience may be a patient safety risk. Purpose: The purpose of the study is to describe the nurse's experiences of being new to emergency care and to examine whether the lack of experience can affect the patient. Method: A qualitative interview study with descriptive design was chosen based on the purpose of the study. Semistructured interviews were conducted with ten nurses who have worked for a maximum of one year at an emergency department in the county of Jönköping. A qualitative content analysis was conducted on a latent level. Results: The categories which form the result of the study are the importance of a good introduction, uncertainty about their own skills, the patient may be affected, experienced staff gave safety and benefits of being new. It emerged that support was a key factor for a successful work. The nurse was not always ready after the introduction to work independently and demanded more practical training. The nurses had created strategies to deal with uncertainty. The lack of experience can affect patient safety. Conclusion: What is considered as a very important factor for well-functioning work is that less experienced nurses have experienced colleagues who can support and assist when needed. The regional community introduction for nurses could be developed to focus more specifically on emergency care. In order to provide the support that the less experienced are in need of, a secured competence is required from the colleagues at the emergency department.

Bakgrund: Besöksantalet på akutmottagningar i Sverige har senaste åren ökat och hög arbetsbelastning är vanligt förekommande. Stort patientantal, för få vårdplatser och långa väntetider leder till stress hos sjuksköterskor och att patientsäkerheten minskar. Sjuksköterskor på akutmottagningar upplever att de är överansträngda och att de ej klarar av att ge den vård de önskar.   Syfte: Belysa hur sjuksköterskor upplever att patienter påverkas av arbetsmiljön på en akutmottagning.   Metod: En kvalitativ studie med 12 sjuksköterskor verksamma på en akutmottagning intervjuades genom semistrukturerade intervjuer. Kvalitativ latent innehållsanalys användes som analysmetod.   Resultat: Resultatet redovisas utifrån ett tema “Arbetsmiljön skapar brister i vården” med två kategorier “Risk för skada hos patienten” och “Negativ upplevelse för patienten”. När arbetsbelastningen är hög blir det brister i omvårdnad, kommunikation och triagering. Resurserna räcker inte till och patienterna får vänta på läkemedel. Patienterna känner sig inte sedda och upplevs vara till besvär. Integriteten blir bristande när arbetsbelastningen är hög och patienterna upplevs få utstå stress och oro av miljön.   Slutsats: Det finns risker för patienterna som söker hjälp på akutmottagningar. Sjuksköterskorna är stressade, glömmer och ger bristfällig vård och behandling. Arbetsmiljön behöver förbättras för att sjuksköterskorna ska ha möjlighet att ge den vård de vill samt den vård som patienterna förtjänar. Riskerna för patienterna är belysta från sjuksköterskornas perspektiv och fortsatt forskning behöver utgå från patienters egna upplevelser. Fortsatt forskning behövs kring rutiner för hur omvårdnaden kan förbättras på akutmottagningar. / Background: The number of visits to emergency departments in Sweden has increased in recent years and high workloads are common. Large patient numbers, lack of care places and long waiting periods lead to stress in nurses and patient safety decreases. Nurses in emergency department feel that they are overworked and unable to provide the care they wish. Objective:  The aim of this study is to clarify nurses’ experiences of how patients are affected by the working environment in an emergency department. Method: A qualitative study of 12 nurses working at an emergency department was interviewed through semi-structured interviews. The analysis has been conducted through a qualitative latent content analysis.   Result: The result is based on a theme "The working environment creates shortages in care" with two categories; "Risk of injury to the patient" and "Negative experience for the patient". When the workload is high, the nursing, communication and triage is lacking. Resources are not enough and patients can wait for medicines. Patients feels unseen and experience they are in the way. The result shows that integrity becomes insufficient when the workload is high and the nurses experience that patients feels stressed and anxious because of the environment.   Conclusion: There are risks for the patients seeking medical care at the emergency department. Nurses are stressed, forgets and provides insufficient care and treatment. The working environment needs to be better for the nurses in order to provide the care they want as well as the care that patients deserve. The risks to the patients are highlighted from the nurse's perspective and continued research needs to be based on the patient's own experiences. Continued research is needed on routines for improving nursing care at emergency departments.

The evaluation of acute chest pain in the emergency department is time-consuming, costly, it is associated with a prolonged length of stay and not rarely the diagnosis is overlooked. The aim of this report was to conduct an overview with meta-analysis to compile evidence from multiple systematic reviews (SRs) related to diagnostic value and prognostic of coronary computed tomography angiography (CCTA) in the assessment of acute chest pain in the emergency departments (ED). We included SRs of primary studies that evaluated the diagnostic value and prognostic of CCTA ≥ 64 channels in the ED. The studies were conducted in patients with low and intermediate risk of CAD with normal cardiac enzymes and nonischemic initial ECG. The quality assessment was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and approved revisions that obtained score ≥ 80%. Two authors independently extracted data using a standardized form. Numerical variables were described as mean and standard deviation and categorical as simple and relative frequencies. We use Spearman correlation test, Chi-square test, Cochran’s Q test or Higgins and Thompson statistical I2. For meta-analysis was used "mada" packet (R Core Team, 2015). Four reviews were eligible for inclusion in this overview, resulting in 13 articles after the criteria of exclusion and only 10 of these were used for meta-analysis. A total of 4831 patients, with a mean age of 54 ± 6 years, 51% male, 46% were hypertensive, 32% had dyslipidemia, 13% diabetes and 26% with family history CAD premature. In the meta-analysis, nine studies defined CCTA positive when presented luminal lesions ≥ 50% and one study ≥ 70%. The sensitivity ranges from 77% to 98% and the specificity ranges from 73% to 100%. The univariate analysis showed homogeneity of DOR [Q = 8.5 (df = 9), p = 0.48 and I2 = 0%]. The pooled mean DOR for CCTA in primary analyses was 4.33 (95% CI: 3.47 - 5.18). The area under the curve (AUC) = 0.982 (95% CI: 0.967 - 0.999). There were no deaths, 29 (0.6%) infarcts, 92 (1.9%) revascularizations and 312 (6.4%) invasive coronary angiography. The diagnosis of ACS occurred in 7.3% of 1655 patients included in the meta-analysis. The use of CCTA as a tool for stratification of patients with cardiovascular risk low or intermediate, which are in the emergency room with chest pain, has high accuracy, safety, reduces length of hospital stay and probably the costs, producing an early diagnosis and more effective in decision making. To assess the value of CCTA in the prevention of future events, studies with more appropriate design and longer follow-up are necessary. / A avaliação da dor torácica aguda no departamento de emergência é laborativa, tem custo elevado, está associada a um tempo de internação prolongado e, não raramente, o diagnóstico é negligenciado. O objetivo deste estudo foi realizar uma overview com meta-análise para compilar evidências a partir de múltiplas revisões sistemáticas (RSs) relacionadas ao valor diagnóstico e prognóstico da angiotomografia das artérias coronárias (ATCCor) na avaliação da dor torácica aguda na emergência. Foram incluídas RSs de estudos primários que avaliaram o valor diagnóstico e prognóstico da ATCCor ≥ 64 canais na emergência. Os estudos foram realizados em pacientes com risco baixo ou intermediário de doença arterial coronária (DAC), com enzimas cardíacas normais, e eletrocardiograma inicial não isquêmico. Para a avaliação da qualidade utilizou-se o PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) e foram incluídas as revisões que obtiveram pontuação ≥ 80%. Dois autores extraíram independentemente os dados utilizando um formulário padronizado. As variáveis numéricas foram descritas como média e desvio padrão e categóricas como frequências simples e relativas. Foram aplicados: o teste de correlação de Spearman, teste do qui quadrado, teste Q de Cochran ou estatística I2 de Higgins e Thompson. Para meta-análise foi utilizado o pacote "mada" (R Core Team, 2015). Quatro RSs foram elegíveis para inclusão nesta overview, resultando em 13 artigos primários, após os critérios de exclusão, e apenas 10 destes foram utilizados para meta-análise. Um total de 4831 pacientes, com idade média de 54 ± 6 anos, 51% do sexo masculino, 46% eram hipertensos, 32% tinham dislipidemia, 13% diabetes e 26% com história familiar de DAC prematura. Na meta-análise, nove estudos definiram a ATCCor positiva quando apresentava lesões luminais ≥ 50% e um estudo quando ≥ 70%. A sensibilidade variou de 77% a 98% e a especificidade variou de 73% a 100%. A análise univariada mostrou homogeneidade da DOR [Q = 8,5 (df = 9), p = 0,48 e I2 = 0%]. A estimativa sumária da DOR para ATCCor nos estudos primários foi de 4,33 (IC 95%: 3,47-5,18). A área sob a curva (AUC) = 0,982 (95% CI: 0,967-0,999). Não ocorreram mortes, 29 (0,6%) infartos, 92 (1,9%) revascularizações e 312 (6,4%) angiografias coronárias invasivas (ACI). O diagnóstico de síndrome coronariana aguda ocorreu em 7,3% dos 1655 pacientes incluídos na meta-análise. Concluímos que o uso da ATCCor como ferramenta para a estratificação de pacientes com risco cardiovascular baixo ou intermediário, que estão na sala de emergência com dor no peito, tem alta precisão, segurança, reduz o tempo de internação e, provavelmente, os custos, conduzindo a um diagnóstico precoce e mais eficaz quando comparado ao cuidado padrão na tomada de decisões. Para avaliar o valor da ATCCor na prevenção de eventos futuros são necessários estudos com desenho mais apropriado e com maior tempo de acompanhamento.

Introdução: A sepse é uma condição clínica de inflamação disseminada e descontrolada associada a um foco infeccioso. É uma condição de difícil estudo pela variedade de interações existentes entre as diversas instâncias do organismo e um conceito uniforme ainda está sendo debatido na literatura, o que dificulta a pesquisa e o estabelecimento de legislação que garanta fomento específico. Somado a isto, a exemplo de outras condições tempo-dependentes como infarto agudo do miocárdio, trauma e acidente vascular cerebral, a organização do fluxo do paciente através do sistema de saúde, garantindo leitos de terapia intensiva é fundamental. A U.E.- HCFMRP-USP é referência terciária para emergências para uma população de aproximadamente 4,5 milhões de habitantes e vem introduzindo mecanismos de gestão de fluxo como a priorização de leitos de terapia intensiva e desospitalização. Estas duas estratégias são recentes no Sistema Único de Saúde (SUS) e sua avaliação é fundamental para identificar o perfil de pacientes com Sepse e a importância da organização do sistema no prognóstico desta condição. Objetivos: 1) Avaliar a associação da priorização de Vagas em Terapia Intensiva com a mortalidade, morbidade e tempo de permanência hospitalar dos pacientes; 2) Avaliar o perfil epidemiológico dos pacientes com Sepse admitidos na U.E.-HCFMRP-USP; 3) Avaliar a estratégia de priorização de vagas no acesso de pacientes em sepse grave ou choque séptico aos leitos de terapia intensiva; 4) Avaliar a estratégia de transferência para leitos de retaguarda na oferta de leitos de terapia intensiva. 5) Avaliar a estratégia de priorização de vagas no retardo ao acesso de pacientes em sepse grave ou choque séptico aos leitos de terapia intensiva; 6) Avaliar a estratégia de priorização de vagas na mortalidade de pacientes em sepse grave ou choque séptico aos leitos de terapia intensiva; 7) Avaliar o índice prognóstico \"Quick\" SOFA nos pacientes com sepse grave ou choque séptico admitidos na U.E.-HCFMRP-USP. Metodologia: Trata-se de uma coorte retrospectiva realizada a partir de dados administrativos obtidos do sistema eletrônico de gerenciamento de pacientes da UEHCFMRP- USP de 01 janeiro de 2010 a 31 de dezembro de 20016. Foram construídas duas bases de dados. A primeira embasada em internação como identificador, na qual foram derivadas variáveis que representam priorização, dados demográficos, Comorbidade (Índice de Comorbidade de Charlson), a gravidade (\"Quick SOFA\"), linha de cuidado, presença de sepse e variáveis de desfecho. A segunda embasada em cada dia do período de estudo composta por variáveis sobre o número de leitos de CTI disponíveis, número de admissões, número de altas, número de transferências para hospital geral e para hospital de retaguarda. As variáveis quantitativas foram expressas como média e desvio-padrão ou mediana e mínimo e máximo de acordo com o teste de normalidade e as variáveis categóricas como percentagem. Para análise univariada foram utilizados testes t de Student, Análise de Variância ou equivalentes não-paramétricos, qui-quadrado ou teste exato de Fisher e \"Receiver Operating\'\' Curves\". Para a análise multivariada foram utilizadas a regressão logística multivariada com desfecho binário ou categórico conforme apropriado e a regressão multivariada de Poisson. A significância estatística foi expressa por p<0,05 ou a exclusão da unidade do intervalo de confiança. Resultados: 1) O processo de priorização de leitos de terapia intensiva se mostrou apropriado. Os pacientes que receberam prioridade maior para acesso ao CTI (prioridade 1- 5826;62,5%) eram mais jovens (55;12-100 - p<0,01), apresentavam menos comorbidades ( Charlson 0, 3583:61,5% - p<0,01) e menor gravidade (Quick\" SOFA\" 0,2170;37,2% - p<0,01; SOFA <10% - 1782;0,5% - p<0,01). Estes pacientes foram admitidos em maior proporção (2097;35,9% - p<0,01) e tiveram acesso mais rápido ao CTI (1081;52,5% - p<0,01), apresentando menor mortalidade (1853;31,8% - p<0,01). Ao se ajustar os possíveis fatores de confusão para estabelecer a razão de chances de receber prioridade 1 pelo intensivista, maior valor da classe de Charlson (Comorbidade) - OR 0,53; 0,49-0,57, do \"Quick SOFA\" (Gravidade) - OR 0,45; 0,43- 0,48 e a presença da condição Sepse - OR 0,20-0,17;0,23 estiveram associados independentemente à menor chance de receber esta classificação. 2) Os pacientes sépticos identificados neste estudo tinham maior idade (61;12-97 - p<0,01), maior prevalência do gênero masculino (646;56,2% - p<0,01) , menor amparo social (714;61,8% - p=0,048), maior índice de Comorbidade (Charlson 2 - 222;19,3% - p<0,01) e de Gravidade (SOFA >90% - 152;13,2% - p<0,01), apresentaram maior mortalidade intrahospitalar (838;73% - p<0,01), maior retardo para admissão no CTI e maior duração da internação hospitalar (7,3;0-304 - p<0,01). Quando comparados com outras linhas de cuidado bem estabelecidas, observou-se que a Sepse pode ser equiparada com o Trauma em termos de incidência (sepse 1148;22,5% - p<0,01; trauma 1138;22,3% - p<0,01), sendo inferior apenas às Síndromes Coronarianas Agudas (SCA)(1972;38,7% - p<0,01). Na análise multivariada, a Sepse está associada à menor chance de receber prioridade 1(0,2 ; IC 95% - 0,17;0,23) independente de outros fatores de confusão, persistiu como fator independente para mortalidade intra-hospitalar total (2,7; IC 95% - 2,32;3,17) e para a mortalidade de pacientes admitidos no CTI (2,38; IC 95% - 1,82;3,11). 3) A priorização de vagas facilitou o acesso dos pacientes ao CTI; 4) A estratégia de transferência de pacientes de alta dependência que deixaram de requerer recursos de alta complexidade se mostrou importante para o sistema. As três instituições parceiras não se distinguiram com relação ao índice de Comorbidade de Charlson (Altinópolis , Charlson 0, 25;28,1%, Charlson 1, 29;32,6%, Charlson 2, 35;39,3%; Guariba Charlson 0, 60;35,7%, Charlson 1, 50;29,7%, Charlson 2, 58;34,5%; São Simão, Charlson 0, 20;28,5%, Charlson 1, 17;24,3%, Charlson 2, 33;47,2% - p=0,894) e tiveram desempenho semelhante com relação à mortalidade(Altinópolis 35;39,33%, Guariba 78;46,4%, São Simão 33;47,1% - p=0,26) e alta domiciliar (Altinópolis 37;41,5%; Guariba 60;35,71%, São Simão 19;27,1% - p=0,26). Os pacientes com problemas neurológicos foram responsáveis pela maioria das transferências (Altinópolis 61;68,5%, Guariba 92;54,7%, São Simão 40;57,1% - p=0,06). Ao longo dos anos, houve melhora do desempenho das instituições com relação à mortalidade (2013,16 óbitos;44,4%, 2016, 37 óbitos;35,2% - p<0,01) e a relação de permanência na U.E.-HCFMRP-USP comparada à permanência total (soma da internação na U.E.- HCFMRP-USP e da internação nos leitos de longa permanência) decresceu (2013, 67,8 dias;0-97,7, 2016, 58,87 dias;0-100 - p=0,005). Na análise multivariada, observou-se que a transferência para leitos de longa permanência foi fator independente em aumentar a disponibilidade de leitosde CTI na U.E.-HCFMRP-USP (com o ano de 2016 1,54; IC 95% - 1,18-2,01, excluindo-se o ano de 2016 1,73; IC 95% - 1,26;2,39). 5) Não houve retardo de admissão no CTI dos pacientes sépticos que receberam prioridade 1 quando se ajustou por possíveis fatores de confusão (0,43; IC 95% - 0,35;0,53); 6) O índice prognóstico \"Quick\" SOFA teve baixa acurácia nos pacientes com sepse grave ou choque séptico admitidos na U.E.-HCFMRPUSP (AUROC= 0,5646, IC95% - 0,52991;0,59930-p<0,001). Conclusões: A Sepse apresentou elevada mortalidade mesmo quando foi garantida a admissão ao CTI em comparação com outros estudos, o que pode refletir o viés de seleção da Regulação Médica. As estratégias de gerenciamento de fluxo foram eficazes em garantir acesso e aumentar a disponibilidade de leitos. / Introduction: Sepsis is a clinical condition of disseminated and uncontrolled inflammation associated with an infectious outbreak. It is a condition difficult to study because of the variety of interactions between the various organs of the organism and lack of a uniform concept in the literature, which makes it difficult to research and establish legislation that guarantees specific promotion. Added to this, like other timedependent conditions such as acute myocardial infarction, trauma and stroke, the organization of patient flow through the health system, ensuring intensive care beds is critical. The U.E.-HCFMRP-USP is a tertiary reference for emergencies for a population of approximately 4.5 million inhabitants and has been introducing flow management mechanisms such as the prioritization of intensive care and de-hospitalization beds. These two strategies are recent in the Unified Health System (SUS) and their valuation is fundamental to identify the profile of patients with Sepsis and the importance of the organization of the system in the prognosis of this condition. Objectives: 1) To evaluate the association of the prioritization of Vacancies in Intensive Care with the mortality, morbidity and hospital stay time of the patients; 2) To evaluate the epidemiological profile of patients with sepsis admitted to U.E.-HCFMRP-USP; 3) Evaluate the strategy of prioritizing vacancies in the access of patients in severe sepsis or septic shock to intensive care beds; 4) Evaluate the transfer strategy for back beds in the offer of intensive care beds. 5) Evaluate the strategy of prioritization of vacancies in the delay to access of patients in severe sepsis or septic shock to intensive care beds; 6) To evaluate the strategy of prioritization of vacancies in the mortality of patients in severe sepsis or septic shock to intensive care beds; 7) To evaluate the \"Quick\" SOFA prognostic index in patients with severe sepsis or septic shock admitted to U.E.- HCFMRP-USP. Methodology: This is a retrospective cohort based on administrative data obtained from the electronic patient management system of the EU-HCFMRP-USP from January 01, 2010 to December 31, 20016. Two databases were constructed. The first was based on admission as an identifier, in which variables were derived, such as prioritization, demographic data, Comorbidity (Charlson Comorbidity Index), severity (\"Quick SOFA\"), clinical pathway, presence of sepsis and outcome variables. The second, based on each day of the study period, contains variables on the number of CTI beds available, number of admissions, number of discharges, number of transfers to general hospital and back hospital. We expressed quantitative variables as mean and standard deviation or median and minimum and maximum according to the normality test and categorical variables as percentage. We used Student t tests, Analysis of Variance or non-parametric equivalents, chi-square or Fisher\'s exact test and \"Receiver Operating Curves\" for univariate analysis. We used Multivariate logistic regression with binary or categorical outcome and multivariate Poisson regression as appropriate for the multivariate analysis. A p <0.05 or the exclusion of the unit from the confidence interval signaled statistical significance. Results: 1) The process of prioritizing intensive care beds was appropriate. Patients who received higher priority for CTI access (priority 1 - 5826;62,5%) were younger (55;12- 100 - p<0,01), had less comorbidities ( Charlson 0, 3583;61,5%, p<0,01) and less severity (Quick\" SOFA\" 0,2170;37,2% - p<0,01; SOFA <10% - 1782;0,5% - p<0,01). These patients were admitted in greater proportion (2097;35,9% - p<0,01) and had faster access to ICU (1081;52,5% - p<0,01), presenting lower mortality (1853;31,8% - p<0,01). When adjusting the possible confounding factors to establish the odds ratio to receive priority 1 by the intensivist, higher value of the Charlson class OR 0,53; 0,49-0,57, the \"Quick SOFA\" (Severity) - OR 0,45; 0,43-0,48 and the presence of Sepsis condition - OR 0,20-0,17;0,23 were independently associated with a lower chance of being classified as priority 1. 2) The septic patients identified in this study had older age (61;12- 97 - p<0,01), higher prevalence of male gender (646;56,2% - p<0,01), lower social protection (714;61,8% - p=0,048), higher Comorbidity (Charlson 2 - 222;19,3% - p<0,01) and Severity index (SOFA >90% - 152;13,2% - p<0,01), higher in-hospital mortality (838;73% - p<0,01), longer ICU admission delay and longer hospital stay(7,3;0-304 - p<0,01). When compared to other clinical pathways, it was observed that Sepsis can be equated with Trauma in terms of incidence (sepsis 1148;22,5% - p<0,01; trauma 1138;22,3% - p<0,01), being inferior only to Acute Coronary Syndromes (ACS) (1972;38,7% - p<0,01). In the multivariate analysis, Sepsis was more associated to lower chance of receiving priority 1(0,2; IC 95% - 0,17;0,23) independent of other confounding factors, it persisted as an independent factor for total in-hospital mortality(2,7; IC 95% - 2,32;3,17) and for the mortality of patients admitted to the ICU(2,38; IC 95% - 1,82;3,11). 3) The prioritization of vacancies facilitated the access of the septic patients to the ICU. 4) The strategy of transference of patients of high dependence that stopped requesting resources of high complexity proved to be important for the system. The three partner institutions did not differ in relation to the Charlson Comorbidity Index (Altinópolis , Charlson 0, 25;28,1%, Charlson 1, 29;32,6%, Charlson 2, 35;39,3%; Guariba Charlson 0, 60;35,7%, Charlson 1, 50;29,7%, Charlson 2, 58;34,5%; São Simão, Charlson 0, 20;28,5%, Charlson 1, 17;24,3%, Charlson 2, 33;47,2% - p=0,894) and had a similar performance in relation to mortality (Altinópolis 35;39,33%, Guariba 78;46,4%, São Simão 33;47,1% - p=0,26) and household discharge (Altinópolis 37;41,5%; Guariba 60;35,71%, São Simão 19;27,1% - p=0,26). Patients with neurological problems were responsible for most of the transfers (Altinópolis 61;68,5%, Guariba 92;54,7%, São Simão 40;57,1% - p=0,06). Over the years, there has been an improvement in the institutions\' performance in relation to mortality (2013,16 deaths;44,4%, 2016, 37 deaths;35,2% - p<0,01) and the length of stay in the EUHCFMRP- USP compared to the total stay (sum of hospitalization in the EU-HCFMRP-USP and length of stay in long-stay beds) decreased (2013, 67,8 days;0-97,7, 2016, 58,87 days;0-100 - p=0,005).In the multivariate analysis, we observed that the transfer to long-stay beds was an independent factor in increasing the availability of ICU beds in U.E.-HCFMRPUSP (with year 2016 1,54; IC - 95% 1,18;2,01, without year 2016 1,73; IC - 95% 1,26;2,39). 5) There was no delay in ICU admission for septic patients who received priority 1 when adjusted for possible confounding factors (0,43; IC 95% - 0,35;0,53).7) The \"Quick\" SOFA prognostic index had low accuracy in patients with severe sepsis or septic shock admitted to U.E.-HCFMRP-USP (AUROC= 0,5646, IC95% - 0,52991;0,59930 - p<0,001).Conclusions: Sepsis presented a high mortality even when admission to the ICU was guaranteed in comparison to other studies, which may reflect the selection bias of the Medical Regulation. Flow management strategies were effective in securing access and increasing bed availability.

In this bachelor thesis, a prototype of a digital tool is designed, aimed at self-registering patient data in an emergency ward. Normally, patients not arriving by ambulance are treated in the order they enter the waiting room. Nurses performing the first examination—a triage—must ask the patient about their identity, previous medical history and similar questions, and enter this data into a new treatment case in the healthcare information system. It has been suggested that having the patient enter this data themselves would be beneficial, allowing nurses to concentrate on the medical issues. After gathering and analyzing data from observations and from interviews with the staff at a Swedish hospital, a prototype of a digital tool was designed, where patients step-by-step could enter the required data in the waiting room, thus saving valuable time in the triage. Benefits for the patient include receiving feedback about the number of persons ahead in line. The prototype was received favorably by test persons and by the staff, indicating that it could work as a model for a product to be put into work use.

Many elderly patients visiting the emergency department for minor injuries are not assessed for functional status and experience functional decline 6 months post injury. Identifying such high-risk patients can allow for interventions to prevent or minimize adverse health outcomes including loss of independence. For the purpose of a planned clinical decision rule to identify elderly patients at high risk of functional decline a survey of physicians was conducted. A random sample of 534 Canadian geriatricians, emergency and family physicians was selected with half randomly selected to receive an incentive. A response rate of 57.0% was obtained with 90% of physicians considering a drop in function of at least 2 points on the 28-point OARS ADL scale as clinically significant. A sensitivity of 90% would meet or exceed 90% of physicians' requirements for a clinical decision rule to identify injured seniors at high risk of functional decline 6 months post injury.

The focus of the diploma thesis is to evaluate the implementation of Jindřichův Hradec Hospital's Emergency department taking into consideration mainly fulfilling the aims targeted when decision about foundation of this department had been made. There are determined four goals that are crucial for the management of the healthcare institution. Based on that, the hypotheses are built. This thesis provides information which could be used by the Jindřichův Hradec Hospital's management in the terms of deciding about quality monitoring or patients satisfaction assessment.

Bakgrund: Pediatriskt trauma är ett internationellt hälsoproblem som kräver att sjuksköterskan har ökad kunskap om barnets och dennes familjs behov, hur barnet reagerar på trauma både psykologiskt och fysiologiskt samt speciella färdigheter för att ge traumavård av god kvalitet. Att ge omvårdnad till dessa patienter kan vara komplext för sjuksköterskan, då vanligtvis även familjen finns närvarande. Syfte: Att undersöka centrala komponenter i omvårdnaden av pediatriska traumapatienter på en akutmottagning. Metod: En litteraturstudie med systematisk datainsamling och analys och kvalitativ metod genomfördes med sökningar ur två databaser. Befintliga data ur vetenskapliga artiklar har granskats och analyserats. Elva kvalitetsgranskade primära studier identifierades till resultatet. Resultat: Tre huvudkategorier analyserades fram. Den första kategorin är Förmedla trygghet. Att ge löpande information, vara stödjande och lugnande med empati och skapa en förtroenderelation var viktigt för att förmedla trygghet. Samspel och stöd var den andra kategorin och det mest framträdande resultatet som tar upp samspelet mellan sjuksköterska, patient och dennes familj. Vid omvårdnad av pediatriska traumapatienter är det inte bara barnet i sig som behöver uppmärksammas, sjuksköterskan behövde se hela familjen och ge stöd, bjuda in till delaktighet och smärtlindra både psykologiskt och fysiologiskt. Organisatoriska förutsättningar är den tredje kategorin som beskriver hur sjuksköterskans kompetens har betydelse för omvårdnadens kvalitet, vilken påverkan tid har och hur sjuksköterskan i sitt samarbete med kollegor kan ge god omvårdnad. Slutsats: Det finns flera komponenter i omvårdnaden av pediatriska traumapatienter och dessa patienter får olika förutsättningar beroende på vilken akutmottagning som tar emot och vilken kompetens som finns på plats. Sjuksköterskan befinner sig i en komplex och stressfylld situation där många olika behov måste tillgodoses. Sjuksköterskans kompetens behöver därför utvecklas kontinuerligt för att skapa trygghet och kunskap om vilka behov som är viktigast att prioritera. / Background: Pediatric trauma is an international health problem which requires that the nurse has increased knowledge of the needs of the child and their family, the child’s response to trauma both psychologically and physiologically, as well as special skills to provide trauma care of good quality. Providing nursing care to these patients can be complex for the nurse, as usually the patient’s family is present. Aim: The aim of this study was to investigate the key components in the nursing care of pediatric trauma patients in an emergency department. Method: A literature study with systematic data collection and analysis with qualitative method was conducted with searches from two databases. Existing data from scientific articles have been reviewed and analyzed. Eleven quality-reviewed primary studies were identified as the result. Results: Three main categories were presented. The first category was to convey safety. Providing ongoing information, being supportive and reassuring with empathy and creating a relationship of trust were important in conveying safety. Interaction and support were the second category and the most dominant, which addressed the interaction between the nurse, the patient and the patient’s family. In the nursing care of pediatric trauma patients, it is not only the child itself that needs attention, but the nurse needed to view the whole family and provide support, invite them to participate and relieve the pain both the psychological and the physical. Organizational conditions were the next category, which described how the nurses skills are important for the quality of nursing care, the impact of time and how the nurse with collaboration with their colleagues, can provide good nursing care. Conclusions: There are several components in the nursing care of pediatric trauma patients and these patients have different prerequisites, depending on which emergency department receives them and the expertise that exists in place. The nurse is in a complex and stressful situation, where many different needs must be met. The nurse’s competence, therefore, needs to be developed constantly, in order to provide security and knowledge of the needs that are most important to prioritize.

Bakgrund: Den vanligaste orsaken till att barn söker vård på en akutmottagning är sjukdom eller skada i de respiratoriska organen. Emellertid är endast en liten andel av dem kritiskt sjuka. Barn har annorlunda anatomi och fysiologi jämfört med vuxna, därav utgör de en komplex patientgrupp vilket är att beakta vid vård av barn. Detta kan innebära stora påfrestningar för såväl vårdande sjuksköterskor som barnet samt barnets närstående och kan generera i en otrygghet för samtliga. Akutsjuksköterskor ska erhålla kunskap om barnets särskilda omvårdnads- och medicinska behov för att kunna identifiera och åtgärda dessa. Att åstadkomma och säkra akut hotad luftväg samt säkerställa god ventilation kan vara sådana åtgärder. Syfte: Syftet var att studera sjuksköterskors upplevelser av att vårda barn med kritisk luftvägs- och andningsproblematik på akutmottagning. Metod: Studien är baserad på en kvalitativ metod med induktiv ansats. Tolv sjuksköterskor intervjuades från fyra olika akutmottagningar i södra Sverige. Intervjuerna analyserades med hjälp Graneheim och Lundmans (2004) tolkning av kvalitativ innehållsanalys och fördes med en latent ansats. Resultat: Analysen genererade i ett övergripande latent tema: ”Små individer kräver stor kunskap”. Temat består av tre kategorier: ”En känslomässig spännvidd”, ”Hämmande delar i vårdandet” och ”Främjande delar i vårdandet” med tolv tillhörande underkategorier. Konklusion: Barn med kritisk luftvägs- och andningsproblematik ställer stora krav på sjuksköterskor såväl känslomässigt som kunskapsmässigt, samtidigt kan sjuksköterskors upplevelser av fenomenet hämmas respektive främjas av diverse delar i vårdandet. / Background: Illness in the respiratory system is the most common reason for children in the emergency department. However, only a small group of these are in a critical ill condition. Children have different anatomy and physiology compered to adults. This in turn means that they are a more complex patient group, which needs to be kept in mind. Since nursing of critical ill children is considered complex this can cause stress for not only the child, but also the child’s family and the nurse in charge of the child’s care. This may lead to insecurity for all involved. The emergency nurse is required to have knowledge about the child’s nursing and medical needs in order to identify and control these. To achieve and secure emergent endangered airway and secure ventilation could be such needs.  Aim: The aim was to study nurses’ experiences of caring for children with critical airway- and breathing problems in the emergency department. Methods: The study is based on a qualitative method with inductive approach. Twelve nurses were interviewed at four different emergency departments in southern Sweden. The interviews were analyzed with qualitative content analysis according to the interpretation of Graneheim and Lundman (2004) and with a latent approach. Findings: The analysis generated into an overall theme: “Small people require big knowledge”. The theme is based on three categories: “An emotional span”, “Inhibitory factors during care” and “Furtherance factors during care” and twelve subcategories.  Conclusions: Children with critical airway- and breathing problems impose high demands on both the knowledge and emotions of the nurse, and the nurse prior experiences of the phenomenon could inhibit as well as promote depending on various parts during care.