Bakgrund: Basala hygienrutiner ska enligt Socialstyrelsen tillämpas för att förebygga vårdrelaterade infektioner (VRI). VRI är ett hot mot patientsäkerheten och kan medföra ökat lidande för patienten och ökade kostnader för samhället. Syfte: Att undersöka följsamhet till basala hygienrutiner inom ambulanssjukvård i ett antal utvalda omvårdnadssituationer. Metod: En deskriptiv kvantitativ studie där data inhämtades genom strukturerad observation. Bekvämlighetsurval tillämpades och totalt 68 observationer gjordes på två ambulansstationer inom samma landsting. Huvudresultat: Följsamhet till basala hygienrutiner varierade, med högst följsamhet till rutinen om kort eller uppsatt hår (87%) samt till användning av handskar (87%). Lägst följsamhet observerades till rutinen om handdesinfektion före patientnära arbete eller användning av handskar (1%). Inte vid någon observation (0%) visades följsamhet till samtliga sju basala hygienrutiner som undersöktes. Slutsats: Att brister av varierande grad fanns i följsamhet till basala hygienrutiner. Särskilt stor förbättringspotential visade de basala hygienrutinerna gällande handdesinfektion före och efter patientnära arbete eller användning av handskar. Bristerna i följsamhet till basala hygienrutiner kan leda till brister i patientsäkerhet i form av en risk att patienter drabbas av VRI och ökat lidande. Orsakerna till resultatet kan troligtvis ligga både på individnivå och organisationsnivå vilket gör det särskilt angeläget att resultatet diskuteras i berörda verksamheter samt fortsatta studier. / Background: According to the Swedish National Board of Health and Welfare, compliance to hygiene routines is important to prevent healthcare-associated infections (HCAI). HCAI are a threat to patient safety and may increase patient suffering and costs for the society. Aim: To describe compliance to hygiene routines within ambulance care in a number of given situations. Method: A descriptive quantitative study with data collection through structured observation. Convenience sampling was used and 68 observations in total were made on two ambulance stations. Main result: Varying compliance to hygiene routines was found, with highest compliance to the routine stating that hair should be short or up (87%) and the routine about use of gloves (87%). The lowest compliance was found to the routine about hand disinfection before patient contact or glove use (1%). No observation showed compliance to all seven hygiene routines covered by the study. Conclusion: That compliance with hygiene routines has shortcomings, especially regarding hand disinfection, which may lead to weak patient safety through a risk of HCAI and patient suffering. The shortcomings are probably grounded both on an individual and an organisational level which makes discussion of the subject in affected organisations and further studies important.

Psykiska störningar är tillstånd som kan drabba alla oss människor. Krav om kompetens på hälso- och sjukvården har ställts för att kunna erbjuda patienter med psykisk störning ett effektivt omhändertagande. Syftet med detta examensarbete är att beskriva ambulanssjuksköterskans erfarenheter av att vårda patienter med psykiska störningar. Metoden är av deskriptiv kvalitativ design och semi-strukturerade intervjuer utgör grunden för den kvalitativa innehållsanalysen med manifest utgångspunkt som genomförts. Resultatet omfattar tre huvudkategorier såsom följer, ’svåra möten skapar rädsla och frustration och försvårar interaktion’, ’svårt bedöma tillstånd och lämpliga åtgärder’ och ’vård byggd med autonomi, erfarenhet och uppfinningsrikedom’. Slutsatsen är att interaktionen mellan patienter och sjuksköterskor byggs av omvårdnadsevidens, att det i sjuksköterskornas bedömningar av tillstånd saknas evidens och att den vård som oftast ges strävas att utgöras av evidensbaserad vård men att det saknas direkta sätt att komma i kontakt med en sådan specialistsjukvård. Det har därmed visats att det finns områden att förbättra och utveckla för att kunna erbjuda patienter med psykisk störning ett effektivt omhändertagande. / Psychiatric disorders are conditions which may afflict every one of us humans. Requirements of competence have been set for the healthcare service to be able to offer an effective emergency care to patients with psychiatric disorder. The aim is to describe the ambulance nurse’s experience by caring for patients with psychiatric disorders. The method is of a descriptive qualitative design and semi-structured interviews constitute the material for the qualitative content analysis, which has been carried out with a manifest basis. The result consist of three main categories as follows, ‘difficult encounters create fear and frustration and complicates interaction’, ‘difficult assessing conditions and appropriate measurements’ and ‘care build with autonomy, experience and inventiveness’. The conclusion is how the interaction between patients and nurses is built by evidence-based nursing, how it is in nurses’ assessments of conditions to be a lack of evidence and how the care most often provided is being strived to constitute of evidence-based healthcare while how it is lacking direct ways to come in contact with such a specialised healthcare. Thus has it been shown that it exist areas for amelioration and evolvement to be able to offer an effective emergency care for patients with a psychiatric disorder.

The study aimed to investigate the acute medical chain consisting of SOS operator, ambulance nurse, emergency nurse and emergency physician with regard to the assessment and prioritization of the victim. The design of this journal study is retrospective with descriptive approach. Data were collected from all ambulance missions carried out in Uppsala county 2009-01-01 between the hours 00:00 to 12:00. Sample period was chosen because the prerequisite for high frequency on the ambulance mission was supposed to be good. In order to be able to systematize the compilation of data a protocol were prepared and used. Applicable data were collected from three databases SOS Alarms, ambulance operations, and the University Hospital in Uppsala. The study was divided into three stages and record documents usefulness was assessed individually based on inclusion criteria's. During the measurement period the SOS operator assessed need of an ambulance at 62 occasions in Uppsala County. Of these 62 ambulance missions there were 18 that could be followed during the whole acute medical chain. The results showed that the participants of the acute medical chain most of the time did the same assessment of the victim main problem/symptom and thus the criterion. Without considering the priority it appeared that the criteria were the same in 83% of all 18 included ambulance missions. SOS operator assessed ambulance mission as a priority one in 39% (7/18), and the ambulance nurse judged that priority one on the way to the hospital was justified in 17% (3/18). Of the 18 victims who were transported by ambulance to the emergency department at the University Hospital in Uppsala 72% (13/18) went home the same day. / Studiens syfte var att undersöka den akutmedicinska vårdkedjan bestående av SOS operatör, ambulanssjuksköterska, akutsjuksköterska och akutläkare med avseende på bedömning och prioritering av drabbad. Designen på denna journalstudie är retrospektiv med deskriptiv ansats. Data insamlades från samtliga ambulansuppdrag som genomfördes i Uppsala län 2009-01-01 mellan klockan 00:00 - 12:00. Urvalsperioden valdes därför att förutsättningen för hög frekvens på ambulansuppdrag förmodades vara goda. För att systematisera sammanställningen av data utarbetades och användes ett protokoll. Tillämpbara uppgifter inhämtades från tre databaser SOS Alarms, ambulansverksamhetens och Akademiska sjukhusets. Studien delades upp i tre steg och journalhandlingarnas användbarhet bedömdes var för sig utifrån inklusionskriterier. Under mätperioden bedömde SOS operatören behov av ambulans vid 62 tillfällen i Uppsala län. Av dessa 62 ambulansuppdrag gick 18 att följa under hela vårdkedjan. Resultatet visade att aktörerna i akutmedicinska vårdkedjan för det mesta gjorde samma bedömning av den drabbades huvudproblem/symtom och därmed kriteriet. Utan hänsyn taget till prioritet så visade det sig att kriterierna övrrensstämde vid 83% av alla 18 inkluderade ambulansuppdrag. SOS operatören bedömde ambulansuppdraget som prioritet ett i 39% (7/18) och ambulanssjuksköterskan bedömde att prioritet ett på väg till sjukhus var motiverat i 17% (3/18). Av de18 drabbade som transporterats med ambulans till akutmottagningen på Akademiska sjukhuset fick 72% (13/18) åka hem samma dag.

Abstract Background: Emergency department (ED) overcrowding has become a significant problem throughout the large medical centers, leading to possible threatened medical quality, causing raised stress levels among staff and patients in EDs, and most importantly, adversely affecting patient outcomes. Due to its complexity, a large concerted group effort will be needed to increase awareness, implement proposed solutions, and make a change. ED overcrowding is a multifaceted problem that will require a multifaceted solution. Methods: We set up the "Input-Throughput-Output" model provides a structure for examining the factors that affect ED access, quality and outcomes. Using this model, we clarify the issues of ED overcrowding into three stages, propose ways to obtain needed information in each stage, test the strategies and then evaluate their outcomes. We utilized the analytic hierarchy process (APH) method to measure the weights of the physician¡¦s stress and arrange more efficacious and flexible duties accordingly. Results: This is a prospective study investigating ED overcrowding at this medical center from January 2008 through December 2009. Hospitals developed and implemented a number of best practices revolved around patient flow initiatives, specifically looking to improve input, throughput, and output. Conclusion: This study suggests that a decrease in ED overcrowding can be achieved through ongoing collaboration of the indicators and the implementation of best practices via the Input-Throughput-Output model.

Situated cognition argues that learning takes place in an embedded social and physical environment, and through a social process, reality takes on meaning. This dissertation investigated if a link exists between learners’ participation and advancement within a sociocultural community of practice as specifically evidenced by higher rates of tracheal intubations on live patients and scores on the national certifying examination by paramedics. During 2006, paramedic students taking the national certifying examination were asked to answer a post-examination questionnaire quantifying the number of intubations performed during training. For intubation experience, significant odds ratios (relative to none performed) were observed for 4 to 9 performed [OR = 1.66, 95% c.i. = (1.24, 2.23)] and 16 or more performed [OR = 1.76, 95% c.i. = (1.21, 2.56)]. The male to female odds ratio [OR = 1.25, 95% c.i. = (1.04, 1.52)] was significant. For age category, significant odds ratios (relative to 40 and over) were observed for 20 to 24 [OR = 1.70, 95% c.i. = (1.27, 2.28)] and 25 to 29 [OR = 1.32, 95% c.i. = (1.00, 1.73)]. For education, the bachelor’s degree to high school odds ratio [OR = 2.56. 95% c.i. = (1.95, 3.35)] was significant. For ethnicity, significant odds ratios (relative to African-Americans) were observed for whites [OR = 1.69, 95% c.i. = (1.04, 2.74)] and others [OR = 2.33, 95% c.i. = (1.15, 4.72)].The multivariable logistic regression model results suggest that the number of tracheal intubations, sex, ethnicity and education level are all associated with greater odds of passing the certifying examination. In addition to traditional classroom lectures and activities, paramedic students also learn in clinical situations with varying levels of supervision culminating in near independent practice. Theories of situated cognition provide insight into these clinical learning situations that break from traditional models. When context, content, and community merge, knowledge is generated in new and meaningful ways. By participating in communities of practice, knowledge is transferred, created, and altered along with the learner through active engagement with all the illstructured, dynamic, and unpredicted opportunities the ‘real world’ offers. The students’ exposure to live tracheal intubations during training serve as an example of situated learning environments and its influence can be observed through the national certifying examination. The findings provide guidance for paramedic educators in creating situative learning affordances and specifically, determining the number of tracheal intubations performed during paramedic training.

Coordination of health and human service transportation programs in rural communities provides a source of sustainable funding for public transit. Significant funding is available for non-emergency medical transportation (NEMT) for Medicaid-eligible clients. In 2009, 21 of the 39 rural transit districts in Texas received NEMT funds under the Texas Medical Transportation Program (MTP). The benefits of MTP funds to rural transit districts are an additional funding source, a consistent cash flow through regular reimbursement for MTP services, and the opportunity to maximize resources (vehicles, miles, hours) by combining MTP passenger trips with general public transit. However, MTP may also increase resources required (miles, hours) to deliver transportation due to program service requirements, resulting in a higher cost per passenger trip and reduced productivity due to longer trip lengths and time. The purpose of this research is to develop a resource-based cost allocation methodology to accurately reflect cost and resources by MTP and general public passenger trip and apply the methodology to five case studies to analyze the impact of MTP trips on general public transit service. Results of the case study analysis reveal that in four of the five case studies, MTP is more resource intensive than general public transportation. MTP passenger trips have longer trip lengths than general public trips ranging from additional mileage per passenger trip of 13 to 40 miles. Using a resource-based cost allocation methodology, in four of the five case studies, MTP trips have higher operating cost per boarding as compared to general public service ranging from a difference of $12 to as much as a $32 per passenger trip. Four of the five case study rural transit districts do not cover the full cost of providing MTP service with MTP revenues with a shortfall ranging from approximately $6.00 per passenger trip to $19.00 per passenger trip. The cumulative impact of MTP on the Texas Performance Funding Formula was found to be positive resulting from the significant positive impact on the local investment indicator. However, the additional funding generated by MTP in the funding formula is still not sufficient to compensate fully for the deficits found.

Emergency departments (EDs) are the only source of medical care for many adults and have been found to be feasible venues for vaccinating high-risk patients against seasonal influenza. Since the CDC guidelines expanded in 2008 to include any adults wishing to protect themselves and those around them from the flu, the vaccination of low-risk patients in the ED has not been evaluated. This study sought to assess the acceptability among adult patients of all ages for vaccinating against seasonal influenza in the Urgent Care area of an urban ED, which treats primarily healthy adults. A convenience sample of adult patients in the Urgent Care area was surveyed in November 2009. Subjects were asked about their vaccination history, as well as their perceived need and potential acceptance of a vaccine in the ED. Demographic data obtained included age, race, education, insurance status, medical history, access to primary care and contact with high-risk individuals. 381 patients were approached, of whom 352 completed the survey (92.4%; 56% male, 44% female; mean age 36 years, Standard Deviation 12.4), and 349 were vaccine-eligible. 250 (72%) denied any significant medical history. While 169 patients (48.4%) had an influenza vaccination history, only 69 (20%) were vaccinated in 2009. Of the 280 not vaccinated this year, 179 (64%) would have accepted the vaccine in the ED. Factors associated with increased odds of vaccine acceptance in the ED included: age younger than 50 years (Odds Ratio [OR] 3.28, 95% Confidence Interval [CI] = 1.74 to 6.21, p<0.01), Latino/Hispanic ethnicity (OR 2.89, 95% CI = 1.52 to 5.51, p<0.01), and close contact with high-risk individuals (OR 2.28, 95% CI = 1.33 to 3.92, p<0.01). These results suggest that the majority of relatively healthy adult patients would accept the seasonal influenza vaccine in the ED. Although a shortage of vaccines and increased vigilance during a concurrent H1N1 outbreak may have influenced overall acceptability, we conclude that influenza vaccinations during the ED patient encounter would generally be acceptable to patients as a means to improve their overall health, and indirectly the health of their high-risk close contacts.

Thesis (Ph. D.)--Indiana University of Pennsylvania. / Includes bibliographical references.

Background “Over-crowding” in Accident and Emergency (A&E) departments of Hong Kong public hospitals with primary care cases not only threatens the service quality of emergency care and prolongs patients’ waiting time for treatment in the A&E departments, but also causes inefficient utilization of resources and deprives true emergency cases of quality care. A local study suggested that 57% of A&E attendances would have been managed better by general practitioner (GP) care. Reasons of the “over-crowding” include: lacking overnight outpatient services in the community, the convenience of A&E departments and the comprehensiveness of emergency services provided in the departments. As a result, there are urgent needs of patients, the society, A&E departments of Hong Kong public hospitals for a feasible solution to divert non-emergent A&E patients to more appropriate primary care services. Objectives To compare the costs and benefits of setting up the proposed 24-hour public emergency clinic inside the A&E department of Prince of Wales Hospital (PWH) for stable ambulatory non-emergent Categories IV and V A&E attendances by conducting a cost-benefit analysis. Methodology Retrospectively compare the costs and benefits of healthcare service provision to A&E attendances in PWH from Feb 2013 to Jan 2014 by cost-benefit analysis. By estimating the patients’ utilization rate of the emergency clinic, the total cost of the proposal is calculated by summarizing the estimated costs of employees’ salaries, capital costs, costs of equipments and treatments provided in the clinic in monetary values. The total benefit of the proposal is calculated by summarizing the estimated benefits of revenues, productivity gain from prevention of prolonged waiting and benefit from emergency diversions in monetary values. Results With the patients’ utilization rate of the clinic estimated as 44%, the total cost of the proposal is estimated as HKD $ 868,863 per month; while the total benefit is estimated as HKD $2,366,695 per month. The net benefit is estimated as HKD $1,497,832 per month with cost-benefit ratio greater than 2.72 of total benefit over total cost. Conclusions The proposal of setting up the 24-hour public emergency clinic in the A&E department of PWH is economically beneficial, and the results are generalizable to other A&E departments of similar acute urban public hospitals in Hong Kong. / published_or_final_version / Public Health / Master / Master of Public Health

In emergency medical transport, “time to definite care” is very important. Emergency medical services and transport medicine agencies have several possible vehicle options for interfacility transfers. Use of a land vehicle, helicopter, or fixed wing aircraft will be dependent on patient condition, distance between sending and receiving hospitals, crew configuration and capabilities, and other factors such as weather and road conditions. This thesis lays out the complex process of patient transfers and highlights the challenges in decision making under time pressure; it then describes the behaviour of human operators in estimating time to definite care. To support the operators in choosing a transportation mode, a decision support tool was built, which provides relevant time estimates for interfacility transfers based on historical dispatch and call data. The goal is to enable operators to make evidence-based decisions on vehicle allocation. A prototype interface was generated and was evaluated through a usability study.