SAMMANFATTNING I Sverige finns 70 sjukhusbundna akutmottagningar varav ett flertal utav dessa har en barnakutmottagning som har dygnsöppen verksamhet. Resterande sjukhus tar emot barn, men bemannas inte av specialiserade barnsjuksköterskor. Vanliga orsaker till att barn uppsöker en akutmottagning är i samband med skada, då de har feber, andningspåverkan eller vid problem med gastrointestinalkanalen. På ett flertal sjukhus används inte någon triageringsmodell för att bedöma barnet, vilket annars anses som en fördel eftersom barnet då bedöms utifrån liknande riktlinjer. Triagering används för att snabbt identifiera den patient som är svårast sjuk och därmed även i behov av snabbast vård och behandling. Patienten prioriteras utifrån fem olika nivåer. Få studier finns som beskriver sjuksköterskans upplevelser av att triagera barn. Därmed finns begränsad information om vilka faktorer som sjuksköterskan upplever påverkar triagen och om dessa inverkar positivt eller negativt på sjuksköterskans arbete. Syftet var att beskriva sjuksköterskors upplevelser av att triagera barn på barnakutmottagning. Sju intervjuer gjordes med sjuksköterskor på två olika barnakutmottagningar i södra Sverige. Intervjuerna var semi-strukturerade och utfördes från december 2014 till och med januari 2015. Som analysmetod användes kvalitativ innehållsanalys. Resultatet indikerar på att sjuksköterskan upplevde en lyckad triage då barnet kände sig tryggt och både triageringen och mätning av de vitala parametrarna då kunde utföras. Föräldrarnas medverkan upplevdes ha en stor del i om barnet kände sig tryggt med sjuksköterskan. Andningsfrekvensen var en vitalparameter som upplevdes svår att mäta. Då en hög arbetsbelastning inträffade upplevde sig sjuksköterskan stressad, vilket påverkade hur triagen utfördes. Triageringen upplevdes som en hjälp för sjuksköterskor med kortare erfarenhet. Sjuksköterskor med längre erfarenhet förlitade sig däremot i större utsträckning på den kliniska blicken. Triagen upplevdes som ett säkert system, både för patienten och för sjuksköterskan. Trygghet infann sig hos sjuksköterskan då barnet bedömdes utifrån samma kriterier och risken för felaktig bedömning ansågs då minskas. Barnets trygghet ger förutsättningar för en lyckad triage. Betydande faktorer tolkas vara stress och tidsbrist, vilket påverkar möjligheten att göra barnet tryggt. För sjuksköterskor med en kortare erfarenhet upplevs triageringen som fördelaktig, då deras beslut grundas på vedertagna riktlinjer. Triageringen tillför en säkerhetsaspekt för sjuksköterskan, såväl som för barnet.

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This research addresses the design and development of a decision support tool to provide healthcare policy makers with insights and feedback when evaluating proposed patient flow and infection mitigation and control strategies in the emergency department (ED). An agent-based modeling (ABM) approach was used to simulate EDs, designed to be tuneable to specific parameters related to specification of topography, agent characteristics and behaviours, and the application in question. In this way, it allows for the user to simulate various ‘what-if’ scenarios related to infection spread and patient flow, where such policy questions may otherwise be left “best intent open loop” in practice. Infection spread modeling and patient flow modeling have been addressed by mathematical and queueing models in the past; however, the application of an ABM approach at the level of an institution is novel. A conjecture of this thesis is that such a tool should be augmented with Machine Learning (ML) technology to assist in performing optimization or search in which patient flow and infection spread are signals or variables of interest. Therefore this work seeks to design and demonstrate a decision support tool with ML capability for optimizing ED processes. The primary contribution of this thesis is the development of a novel, flexible, and tuneable framework for spatial, human-scale ABM in the context of a decision support tool for healthcare policy relating to infection spread and patient flow within EDs . The secondary contribution is the demonstration of the utility of ML for automatic policy generation with respect to the ABM tool. The application of ML to automatically generate healthcare policy in concert with an ABM is believed to be novel and of emerging practical importance. The tertiary contribution is the development and testing of a novel heuristic specific to the ML paradigm used: Genetic Programming (GP). This heuristic aids learning tasks performed in conjunction with ABMs for healthcare policy. The primary contribution is clearly demonstrated within this thesis. The others are of a more difficult nature; the groundwork has been laid for further work in these areas that are likely to remain open for the foreseeable future.

The overall aim of this thesis was to investigate patient safety in the emergency department (ED) and to determine whether this varies according to patient safety culture, waiting, and outcomes of efficiency and quality variables. I: Patient safety culture was described in the EDs of two different hospitals before and after a quality improvement project. The questionnaire “Hospital Survey on Patient Safety Culture” was used to investigate the patient safety culture. The main finding was that the staff at both hospitals scored more positively in the dimension Team-work within hospital after implementing a new work model aimed at improving patient flow and patient safety in the ED. Otherwise, we found only modest improvements. II: Grounded theory was used to explore what happens in the ED from the staff perspective. Their main concern was reducing patients’ non-acceptable waiting time. Management of waiting was improved either by increasing the throughput of patient flow by structure pushing and by shuffling patients, or by changing the experience of waiting by calming patients and by feinting to cover up. III: Three Swedish EDs with different triage models were compared in terms of efficiency and quality. The median length of stay was 158 minutes for physician-led team triage compared with 243 and 197 minutes for nurse–emergency physician and nurse–junior physician triage, respectively. Quality indicators (i.e., patients leaving before treatment was completed, the rate of unscheduled return within 24 and 72 hours, and mortality rate within 7 and 30 days) improved under the physician-led team triage. IV: Efficiency and quality variables were compared from before (2008) to after (2012) a reorganization with a shift of triage model at a single ED. Time from registration to physician decreased by 47 minutes, and the length of stay decreased by 34 minutes. Several quality measures differed between the two years, in favour of 2012. Patients leaving before treatment was completed, unscheduled return within 24 and 72 hours, and mortality rate within 7 and 30 days all improved despite the reduced admission rate. In conclusion, the studies underscore the need to improve patient safety in the ED. It is important to the patient safety culture to reduce patient waiting because it dynamically affects both patients and staff. Physician-led team triage may be a suitable model for reducing patient waiting time and increasing patient safety.

Antalet äldre människor ökar i samhället och står för en allt mer växande grupp patienter som behöver vård på akutmottagningen. Väntetiden på akutmottagningar runt om i landet blir allt längre. Det är ett välkänt faktum att äldre människor påverkas av att vänta länge på en akutmottagning, då deras allmäntillstånd lätt kan försämras på grund av det biologiska åldrandet och grundsjukdomar som gör dem skörare. Syftet med studien var att beskriva äldre patienters upplevelser av väntan vid besök på akutmottagningen. En litteraturstudie utfördes där resultatet baserades på tio vetenskapliga artiklar. Resultatet av denna litteraturöversikt delades in i fyra teman: att bli sedd, att bekräftas i sitt lidande, att vara delaktig som patient och att se patientens hela situation. Behovet hos den äldre att bli bekräftad, att få information och omvårdnad ökade när väntetiden blev lång på akutmottagningen. En ökad medvetenhet hos sjuksköterskan behövs kring den äldre akut sjuka patientens utsatta situation på akutmottagningen. Genom ökad kunskap och medvetenhet kan dessa patienternas behov av omsorg och omvårdnad mötas så deras lidande minskar under väntan på akutmottagningen. Behov av fortsatt forskning kring förbättringar avseende miljön och omhändertagandet av den äldre patienten på akutmottagningen finns vilket även behöver belysas inom grundutbildningen till sjuksköterska. / The number of elderly people is constantly increasing in the community and represents a growing group of patients who need care in the emergency department. The waiting time in the emergency deparments in Sweden tends to become longer. It’s a wellknown fact that older people are affected when they have to wait for a long time. Their general condition could easily detoriate as they are more vulnerable due to biological aging and medical conditions. The aim of the study was to describe older patient’s experiences of waiting in the emergency department. The study was conducted as a literature review and was based on ten scientific articles. The result of this literature review was divided into four themes: to be seen, to be acknowledged in their suffering, to participate as a patient and to see the patient’s entire situation. The older patient’s need to be acknowledged, information and care increased when the waiting time become long. For the nurse, an increased awareness of the older acutely ill patients situation in the emergency department is needed. With more knowledge and awareness, these patients’ needs could be taken care of and their suffering during the waiting time could be reduced. Continued research is needed to improve the environment and care of the older patient and should also be emphasized in nursing education.

I assessed the accuracy of two clinical prediction rules, the d-dimer blood test and point of care ultrasound for diagnosing lower limb deep vein thrombosis. Emergency physicians were trained in ultrasound and prospectively scanned emergency department patients with suspected deep vein thrombosis. Accuracy of the Wells and AMUSE rules and the ultrasound result was compared to radiology-performed ultrasound and a 90-day clinical outcome. Univariate and multivariate analyses were performed assessing which factors were associated with the outcome. The sensitivity and specificity of the Wells score for the clinical outcome was 85.7% and 68.5%; the AMUSE score 85.7% and 54.4%. Ultrasound had a sensitivity of 91.7% and specificity of 91.7% for radiology-diagnosed thrombus and 78.6% and 95.0% for clinical outcome. The odds ratio of a positive outcome with a positive ultrasound was 65.1. After receiving the ultrasound training program, emergency physicians were unable to demonstrate sufficient accuracy to replace current diagnostic strategies.

This research addresses the design and development of a decision support tool to provide healthcare policy makers with insights and feedback when evaluating proposed patient flow and infection mitigation and control strategies in the emergency department (ED). An agent-based modeling (ABM) approach was used to simulate EDs, designed to be tuneable to specific parameters related to specification of topography, agent characteristics and behaviours, and the application in question. In this way, it allows for the user to simulate various ‘what-if’ scenarios related to infection spread and patient flow, where such policy questions may otherwise be left “best intent open loop” in practice. Infection spread modeling and patient flow modeling have been addressed by mathematical and queueing models in the past; however, the application of an ABM approach at the level of an institution is novel. A conjecture of this thesis is that such a tool should be augmented with Machine Learning (ML) technology to assist in performing optimization or search in which patient flow and infection spread are signals or variables of interest. Therefore this work seeks to design and demonstrate a decision support tool with ML capability for optimizing ED processes. The primary contribution of this thesis is the development of a novel, flexible, and tuneable framework for spatial, human-scale ABM in the context of a decision support tool for healthcare policy relating to infection spread and patient flow within EDs . The secondary contribution is the demonstration of the utility of ML for automatic policy generation with respect to the ABM tool. The application of ML to automatically generate healthcare policy in concert with an ABM is believed to be novel and of emerging practical importance. The tertiary contribution is the development and testing of a novel heuristic specific to the ML paradigm used: Genetic Programming (GP). This heuristic aids learning tasks performed in conjunction with ABMs for healthcare policy. The primary contribution is clearly demonstrated within this thesis. The others are of a more difficult nature; the groundwork has been laid for further work in these areas that are likely to remain open for the foreseeable future.

Antalet patienter som söker sig till akutmottagning på grund av smärta är mycket omfattande. Smärta är en subjektiv upplevelse, därför är smärtlindring en komplex omvårdnadshandling som ställer höga krav på sjuksköterskans kompetens. Syftet med litteraturstudien var att belysa vad som påverkar sjuksköterskors omvårdnad vid smärtlindring av vuxna patienter på akutmottagning. Studien genomfördes med en systematisk litteratursökning med utgångspunkt i problemformuleringen. Genom strukturerade sökningar identifierades, granskades och analyserades relevant forskning inom området. I resultatet framkom tre övergripande teman som påverkar sjuksköterskors omvårdnad vid smärtlindring av vuxna patienter på akutmottagning; Sjuksköterskors smärtbedömning, Sjuksköterskors uppfattningar och prioriteringar samt Sjuksköterskors arbetsförhållanden. Resultatet visar att majoriteten av sjuksköterskor underskattar patienters smärta. Sjuksköterskors individuella uppfattning av smärta har en stor påverkan på omvårdnaden vid smärtlindring. Prioritering av smärta som företeelse är en förutsättning för smärtlindring. Miljön på akutmottagningar gör att sjuksköterskor upplever sig oförmögna att ge tillfredställande omsorg till patienter i smärta. Stöd från ledning samt andra professioner är en förutsättning för sjuksköterskor att kunna tillgodose bästa möjliga omvårdnad vid smärtlindring. Vidare forskning angående patienters upplevelse av omvårdnad vid smärtlindring kan öka förståelsen och medvetenheten hos sjuksköterskor. / Pain is one of the most frequent reason for patient´s seeking emergency care. Pain management is a crucial task in nursing due to the fact that pain is a subjective experience. This study aimed to illuminate what affects nursing care of adult patient´s seeking emergency care because of pain. Through a systematic literature search relevant research were identified, reviewed and analyzed. The results presents three themes; Nurse´s pain assessment, Nurse´s perceptions and priorities and Nurse´s working conditions. The results indicates that a majority of nurse´s underestimate patient´s pain. Nurse´s individual perception of pain has a large impact on nursing care regarding pain management. Priority of pain as a phenomenon is essential for pain management. Nurse´s define themselves as patients advocates but because of the emergency department environment they feel unable to provide satisfactorily care for patient´s in pain. Organizational support and teamwork is a presumption to enable best-practice in nursing pain management. Further research regarding patient´s perceptions of nursing care in pain management is required to enhance nurse´s understanding and awareness of pain and pain management.

Emergency department (ED) overcrowding is a challenge faced by many hospitals. One approach to mitigate overcrowding is to anticipate high levels of overcrowding. The purpose of this study was to forecast a measure of ED overcrowding four hours in advance to allow clinicians to prepare for high levels of overcrowding. The chosen measure of ED overcrowding was ED length of stay compliance measures set by the Ontario government. A feed-forward artificial neural network (ANN) was designed to perform a time series forecast on the number of patients that were non-compliant. Using the ANN compared to historical averages, a 70% reduction in the root mean squared error was observed as well as good discriminatory ability of the ANN model with an area under the receiver operating characteristic curve of 0.804. Therefore, using ANNs to forecast ED overcrowding gives clinicians an opportunity to be proactive, rather than reactive, in ED overcrowding crises.

Emergency department (ED) overcrowding is a challenge faced by many hospitals. One approach to mitigate overcrowding is to anticipate high levels of overcrowding. The purpose of this study was to forecast a measure of ED overcrowding four hours in advance to allow clinicians to prepare for high levels of overcrowding. The chosen measure of ED overcrowding was ED length of stay compliance measures set by the Ontario government. A feed-forward artificial neural network (ANN) was designed to perform a time series forecast on the number of patients that were non-compliant. Using the ANN compared to historical averages, a 70% reduction in the root mean squared error was observed as well as good discriminatory ability of the ANN model with an area under the receiver operating characteristic curve of 0.804. Therefore, using ANNs to forecast ED overcrowding gives clinicians an opportunity to be proactive, rather than reactive, in ED overcrowding crises.