Nyckelord: Barnmisshandel, akutmottagning, sjuksköterska, upptäcka, svårigheter   SAMMANFATTNING Bakgrund: Barnmisshandel är ett hälsoproblem som förekommer över hela världen. Globalt sett är 7 % av barn med skador som söker vård på akutmottagningar utsatta för övergrepp. Forskning visar att många barn som är utsatta för övergrepp eller omsorgssvikt besöker barnakutmottagningar utan att deras utsatthet uppdagas och anmäls till myndigheter. En bidragande orsak anses vara sjuksköterskors bristande kunskap hur barnmisshandel upptäcks.  Syfte: Syftet var att undersöka sjuksköterskors upplevda svårigheter att upptäcka barn som far illa i samband med besök på barnakutmottagning och i pediatrisk slutenvård. Metod: Litteraturöversikt med en deduktiv ansats. Artiklar har sökts i databaserna: Psycinfo, Pubmed och Cinahl. I översikten har 14 vetenskapliga artiklar inkluderats.  Resultat: Resultatet visar på flera brister såsom tidsbrist och hög arbetsbelastning samt avsaknaden av rutiner och riktlinjer. Detta är försvårade för sjuksköterskans bedömningsprocess av barnet. Erfarenhet gjorde att sjuksköterskan vågade lita på sin intuition och samtidigt vara professionell i mötet med föräldrar. Närmare kontakt och samarbete med barnrättsinstitutioner för att få mer kunskap om barnmisshandel efterfrågades. Sjuksköterskor ville vara barnets advokat men oroades ofta över vem som skulle få betala priset vid en anmälan. Slutsats: Konsekvenserna av fysisk och/eller psykisk misshandel under barn och ungdomars uppväxt kan bli svåra och bestående. Trots att lagen om anmälningsskyldighet vid misstanke om att ett barn far illa är enkel att förstå upplever många barnsjuksköterskor att lagen kan vara svår att efterleva. Riktlinjer, utbildning och rutiner på arbetsplatsen om barn som far illa är avgörande för barnsjuksköterskan för att kunna upptäcka och förhindra förekomsten av barnmisshandel.

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Hospital emergency departments (EDs) serve a critical role in its non-discriminatory evaluation and stabilization of all individuals who present for care, regardless of ability to pay. However, EDs are not adequately prepared or capable of caring for children and adolescents who are in behavioral health crisis and require acute treatment. The frequency and duration of pediatric ED visits have also increased over time, leading to crowded EDs, suboptimal delivery of behavioral health care, and strain on hospital resources. In response, hospital systems, states, and the federal government developed a variety of policies to support EDs in the delivery of high-quality care and improve pediatric behavioral health outcomes. Numerous drivers involving the low supply of pediatric behavioral health care professionals, high demand for emergency behavioral health evaluation and treatment, and fragmentation of the behavioral health care system interact to continue to drive patients to EDs despite the implemented policies. Further investigations are needed to exactly determine patients’ unmet needs and identify root causes of pediatric behavioral health ED visits. Last, pediatric behavioral health care policy must not only expand on individual policy successes but also take innovative, value-based approaches to effectively address the worsening pediatric behavioral health crisis.

Palliative care (PC) is the comprehensive management of patients diagnosed with terminal illness. Care for PC patients focuses on relieving symptoms. The purpose of this study was to determine the difference between pretest and posttest scores on the Frommelt Attitude towards the Care of the Dying (FATCOD) and the Palliative Care Quiz for Nurses (PCQN) after an educational intervention to emergency department (ED) nurses. The framework for this project was Bandura's social cognitive theory. The FATCOD was used to assess ED nurses' attitudes toward PC, and the PCQN was used to assess ED nurses' knowledge about PC prior to the educational program. The educational intervention was developed using evidence obtained from the literature review and guided by the PCQN. The program presented to the ED nurses covered the essentials of palliative care and the information and skills needed by the ED nurse caring for the PC patient. The FATCOD and the PCQN were then administered as a posttest. A total of 70 nurses from two ED units volunteered to take part in the project. Results of the PCQN pre- and posttest showed a significant difference (p < .05), and the FATCOD pre- and posttest showed no significant difference (p = .849). The results revealed that education significantly improved knowledge of PC for the ED nurses participating in the project. Attitudes about PC were not significantly changed after the education program. The project promotes positive social change by raising awareness of the need for PC educational opportunities for ED nurses. By improving PC in the ED, patients and their families may experience increased satisfaction with end-of-life care and improved quality of life.

Communication is vital to improve patient care outcomes, especially with high acuity patients. Pregnant patients differ from other patient populations because their care involves 2 entities: the patient (mother-to-be) and her unborn fetus. There has been a noted gap in communication and care collaboration between the emergency department (ED) and obstetric (OB) teams at the project site, resulting in delays for patients and lack of appropriate maternal/fetal assessment and contributing negatively to patients' experiences. Using transitions theory and the Rosswurm and Larrabee model, a clinical practice guideline (CPG) inclusive of an obstetrically focused algorithm was developed and presented for use as a communication and care collaboration tool. The implications of this project for nursing practice and positive social change include improved communication and care collaboration at an interdepartmental level when this high acuity patient population presents to the ED for care. The CPG was presented at 3 discussion sessions with 51 administrators, managers, educators, and/or charge nurses from the ED and OB departments of the project site. Overall, nurses reacted positively to the practice guideline and barriers were identified. A qualitative descriptive design was used for this project. Examples of codes identified included 'only 1 portable fetal monitor' and 'new ED nurses don't know whom to call.' From the codes, 3 categories surfaced: (a) education, (b) prioritization, and (c) equipment; and 1 theme emerged: preimplementation needs. The potential impact on pregnant patients who present to the ED after this CPG is fully implemented might be to reduce delays in the ED, ensure patient safety, and improve patients' experiences.

Indiana University-Purdue University Indianapolis (IUPUI) / Healthcare industry in United States of America is facing a big paradox. Although US is a leader in the industry of medical devices, medical practices and medical researches, however there isnt enough satisfaction and quality in performance of US healthcare operations. Despite the big investments and budgets associated with US healthcare, there are big threats to US healthcare operational side, that reduces the quality of care. In this research study, a step by step Systems Engineering approach is applied to improve healthcare delivery process in an Emergency Department of a hospital located in Indianapolis, Indiana. In this study, different type of systems engineering tools and techniques are used to improve the quality of care and patients satisfaction in ED of Eskenazi hospital. Having a simulation model will help to have a better understanding of the ED process and learn more about the bottlenecks of the process. Simulation model is verified and validated using different techniques like applying extreme and moderate conditions and comparing model results with historical data. 4 different what if scenarios are proposed and tested to find out about possible LOS improvements. Additionally, those scenarios are tested in both regular and an increased patient arrival rate. The optimal selected what-if scenario can reduce the LOS by 37 minutes compared to current ED setting. Additionally, by increasing the patient arrival rate patients may stay in the ED up to 6 hours. However, with the proposed ED setting, patients will only spend an additional 106 minutes compared to the regular patient arrival rate.

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Background: Many different patient groups arrive to the emergency department often without an investigated diagnose. Deficiencies in nurses' work environment and the shortcomings of nursing education create challenges for nurses to meet the needs of all these patient groups through nursing based on scientific knowledge. Aim: The aim of this study was to describe nurses’ experiences of insufficient knowledge in nursing situations in the emergency department and what the experiences are perceived to depend on. Method: A literature study of eleven qualitative articles was done based on qualitative content analysis. Result: Two themes were identified; inadequate education and experience and attitudes and conceptions. Conclusion: Varying patient presentations in the emergency department can lead to nurses experiencing inadequate knowledge. These experiences are perceived primarily to be due to inadequate experience but perceptions that nurses should not be expected to have knowledge of unusual patient groups also existed.

Introduktion: Vistelsen på akutmottagningen präglas av möten med flera olika vårdprofessioner. När vårdpersonalen engagerar patienten i en öppen dialog ökar patienternas delaktighet samt patientsäkerheten. Bristande bemötande kan leda till att patientsäkerheten äventyras samt onödiga kostnader då obefogade åtgärder genomförs. Missnöjda patienter till följd av bristande bemötande är mindre benägna att följa vårdens rekommendationer vilket kan leda till att de återkommer till vården i sämre skick.  Syfte: Att undersöka patienters upplevelser av vårdpersonalens bemötande på akutmottagningen. Metod: En deskriptiv kvalitativ litteraturstudie användes som metod. Elva vetenskapliga artiklar med kvalitativ ansats kvalitetsgranskades och analyserades.  Resultat: Fem huvudkategorier framträdde: Information, Kommunikation, Delaktighet, Personcentrerad vård och Personalens handlingar. Att vara tillräckligt informerad, erhålla individanpassad information samt regelbundet kommunicera med vårdpersonal bidrog till en positiv upplevelse av vårdpersonalens bemötande. Även möjligheten att delta i sin vård samt vårdas ur ett personcentrerat förhållningssätt bidrog till positiva upplevelser. När informationen och kommunikationen brast upplevde patienterna oroskänslor.  Slutsats: Mötet präglas av olika faktorer som bidrar till upplevelsen av bemötandet. Varje persons upplevelse är individuell och det är sjuksköterskans ansvar att bemöta personen utifrån dennes individuella behov och önskemål. Ett gott bemötande bidrar till en positiv vårdupplevelse hos den sjuke. När personen inte upplever att bemötandet är tillfredsställande bidrar detta till en negativ vårdupplevelse. / Introduction: Visiting the emergency department is characterized by encounters with different healthcare professions. When the staff engages the patient in an open dialogue patient participation and patient safety increases. Inadequate treatment can lead to patient safety being compromised as well as unnecessary costs when unjustified measures are carried out. Dissatisfied patients, due to poor treatment, are less likely to follow recommendations, leading to them later returning to the hospitals in worse conditions.  Aim: To investigate patients’ experiences of the encounter with the staff in the emergency department.  Method: A descriptive qualitative literature study where eleven scientific articles with a qualitative approach were quality reviewed and analyzed.  Result: Five main categories emerged: Information, Communication, Participation, Person-centered care, and Staff actions. Being sufficiently informed, receiving individually tailored information and regular communication with healthcare staff contributed to a positive experience of the treatment. To be involved in their care and to be cared for from a person-centered approach also contributed to positive experiences. When information and communication was insufficient patients experienced negative emotions.  Conclusion: Being cared for in an emergency department implies an encounter between a patient and staff. The encounter is characterized by various factors that contribute to the experience of being treated at the emergency department. Each persons’ situation is individual, and it is the nurses’ responsibility to respond to the person based on their individual needs. A good encounter contributes to a positive experience for the patient. When the encounter is unsatisfactory it contributes to a negative experience.

Introduction: Long term care (LTC) residents require complete or extensive support, including 24-hour nursing and personal care. LTC residents contribute a greater number of emergency department (ED) visits when compared to community-dwelling older adults. Little is known about which resident-level characteristics at admission are predictive of LTC resident transfer to the ED. The objective of this thesis was to identify which admission characteristics are associated with ED transfers in Ontario, Canada. Methodology: I conducted a population-level retrospective cohort study using the Resident Assessment Instrument Minimum Data Set Version 2.0 (RAI-MDS). The cohort included 56,433 LTC resident admission assessments from January 1, 2017, to December 31, 2018. Logistic regression and 10-fold cross-validation were used to identify adjusted associations between characteristics routinely collected during LTC admission assessment and ED transfers. Model performance was assessed using the area under the receiver operating characteristics curve (AUC). Outcomes of interest included any ED use, potentially preventable, and low acuity ED transfers. Results: A recent change in medical orders, previous ED visitation, female sex, the presence of an indwelling catheter, and the need for oxygen therapy were informative predictors for any, potentially preventable, and low acuity ED transfers. Deterioration in cognitive status and change in behavior was influential to any ED transfers only. Urinary tract infections, pneumonia, indictors of delirium, and change in mood are unique to potentially preventable ED transfers, and antibiotic resistance is unique to low acuity ED transfers. Similar discrimination was reached for any ED use (AUC = 0.630), potentially preventable transfers (AUC = 0.659), and low acuity transfers (AUC = 0.645). Conclusion: The factors associated with ED transfers may be modifiable, and closer attention to these factors may help reduce ED transfers. Although the discriminability of the models was poor, advanced knowledge of informative characteristics can support upstream decision-making for clinicians. Future studies are required to validate these findings, derive risk scales, and demonstrate the utility of this model in health service planning. / Thesis / Master of Science (MSc) / Long term care (LTC) provides residents with 24-hour nursing and personal care. When the care or clinical needs of the resident cannot be met in the LTC facility, they may be transferred to the Emergency Department (ED). However, the ED’s are poorly situated to manage the distinct needs of older adults, given the sole focus on medical acuity rather than geriatric complexity. Unwarranted ED transfers are burdensome for LTC residents and increase their risk for adverse health events, such as nosocomial infections, delirium, and injuries. Understanding characteristics associated with ED transfers can help identify which residents may be at a risk of an ED transfer. The objective of this thesis was to identify which LTC resident characteristics at admission are associated with ED transfers in Ontario, Canada. A recent change in medical orders, previous ED visitation, female sex, the presence of an indwelling catheter, and the need for oxygen therapy were informative predictors for ED transfers.