O pronto socorro é uma unidade do hospital destinada à assistência a pacientes externos com ou sem risco de morte, que necessitam de atendimento imediato, cujo funcionamento se dá nas 24 horas do dia sendo fundamental a determinação do número necessário de profissionais de enfermagem para prestar assistência com qualidade satisfatória, pois a falta de profissionais de enfermagem com diferentes níveis de formação e a sobrecarga de trabalho aumentam o risco de ocorrência de falhas com prejuízo da qualidade na assistência ao paciente. Os instrumentos de classificação de pacientes são utilizados pela enfermagem em qualquer unidade assistencial e estabelecem as características da população assistida de acordo com a necessidade de cuidados requerida, sendo indispensável para a determinação das necessidades de pessoal e alocação quantitativa e qualitativa dos mesmos. Com o objetivo de caracterizar o perfil assistencial dos pacientes adultos durante a internação no pronto-socorro como um dos subsídios para o dimensionamento do pessoal de enfermagem desenvolveu-se uma pesquisa exploratória no método do estudo de caso, em um pronto-socorro, clínico e cirúrgico, de um hospital geral, público estadual que possui 24 leitos de observação e dez leitos na unidade de atendimento de emergências, localizado no extremo leste do município de São Paulo que trabalha com demanda espontânea do usuário. Os sujeitos da pesquisa foram os pacientes adultos internados na unidade de emergência e nas salas de observação durante o mês de janeiro de 2009, os dados foram coletados por meio da aplicação do instrumento de classificação de pacientes de Fugulin (2002) que avalia nove áreas de cuidado (Estado mental, Oxigenação, Sinais Vitais, Motilidade, Deambulação, Alimentação, Cuidado Corporal, Eliminação e Terapêutica). Foram realizadas 1.228 avaliações, sendo verificados 91 pacientes na categoria de cuidados intensivos, 75 na categoria de cuidados semi-intensivos, 245 com alta dependência para assistência de enfermagem, 272 com complexidade assistencial intermediária e 545 com a mínima. Houve a constatação de muitos pacientes da psiquiatria internados no pronto-socorro a espera de vagas para internação na unidade especializada requerendo da equipe de enfermagem uma assistência diferenciada para a manutenção da integridade física desses pacientes. Verificou-se por meio do número médio mensal de atendimentos realizados que a maioria dos usuários do pronto-socorro não necessitava de internação mas foram atraídos para esse serviço em busca de consultas de rotina acabando por sobrecarregar a equipe multiprofissional que atua nessa unidade que apresentou uma taxa de ocupação média acima da previsão dos leitos oficiais disponíveis tornando a planta física inadequada para pacientes e profissionais devido às internações em macas pelos corredores, reflexo da falta de um serviço de regulação. / The emergency medical service is the hospital ward designated to outpatient care with or without death risk for those who need immediate care, whose attendance is 24 hours a day, being essential the determination of a required number of nursing professionals for delivering satisfactory quality care, since the lack of nursing professionals with different levels of background and work overload increase the risk of errors, impairing the quality of patient care. The instruments of patient classification are used by nursing in any care ward and set up the characteristics of the population assisted, according to the need of care required, being vital for determining the personnel needs and its quantitative and qualitative allocation. Aiming to characterize the adult patient care profile throughout the admission at the emergency medical service, as a support for nursing personnel dimensioning, it was developed an exploratory research in a study of case method, at a clinic and surgical emergency room of a general, public state hospital that holds 24 observation beds and 10 beds at the emergency attendance ward, located at the extreme east of São Paulo city and which works with spontaneous demand of users. The subjects of research were adult patients admitted at the emergency ward and the observation rooms throughout the month of January, 2009. Data was collected through the application of an instrument of patient classification by Fugulin (2002), which evaluates nine care areas (Mental Status, Oxygenation, Vital Signs, Motility, walking, Feeding, Body Care, Elimination and Therapeutics). It was made 1228 evaluations, in which 91 patients in the intensive care category were verified, 75 in the semiintensive care, 245 with high dependence of nursing care, 272 with intermediate care complexity and 545 with minimal one. There was the evidence of many psychiatric patients admitted in the emergency room waiting for a vacancy in the specialized ward requiring from the nursing staff special care for keeping the physical integrity of those patients. It was verified by the monthly average number of attendance that most emergency room users didnt need admission, but they were attracted to this service in search for routine appointments, leading to overload the multi-professional team that works in this ward, which presented an average occupancy rate above the prediction of official beds available, making the physical space inadequate for patients and professionals, due to the admissions in beds spread in corridors, result of lack of service control.

Submitted by Fabricia Fialho Reginato (fabriciar) on 2015-06-26T23:28:54Z No. of bitstreams: 1 FabianodeFaveri.pdf: 1884088 bytes, checksum: 0ae1239ef4be06607d58cf7627341f11 (MD5) / Made available in DSpace on 2015-06-26T23:28:54Z (GMT). No. of bitstreams: 1 FabianodeFaveri.pdf: 1884088 bytes, checksum: 0ae1239ef4be06607d58cf7627341f11 (MD5) Previous issue date: 2013-09-27 / Nenhuma / Na busca da melhoria geral dos cuidados de saúde, organizações em diferentes países vêm adotando o Lean Thinking. Tal método consiste em uma abordagem sistemática de identificação e eliminação de desperdícios dos processos produtivos, enquanto tem o seu foco principal em agregar a qualidade e entregar ao cliente somente o que ele considera como valor. OBJETIVO: identificar os diferentes tipos de desperdícios existentes e sugestões de melhorias, no serviço de emergência de um hospital privado de Caxias do Sul, Rio Grande do Sul. MÉTODO: trata-se de um estudo de caso realizado em um serviço de emergência de um hospital da cidade de Caxias do Sul. A amostra foi constituída de 14 profissionais que atuam no serviço de emergência, além de 68 fluxos de atendimentos de pacientes. Para coleta de dados foi realizada a observação dos fluxos de trabalho associada à realização de grupo focal. Os dados quantitativos foram analisados através da estatística descritiva e os dados qualitativos através da análise de conteúdo. RESULTADOS: dos oito tipos de desperdícios abordados pela metodologia Lean Thinking, foram identificados no serviço sete delas: desperdício por espera, transporte desnecessário, movimentação desnecessária, inventários desnecessários, processamento inapropriado, defeitos e desperdício de potencial humano. CONCLUSÃO: A aplicação do Lean Thinking no serviço de emergência facilitou a determinação do que realmente é valor agregado, para o usuário do serviço. Sem sombra de dúvida metodologia facilita a visualização dos processos de trabalho e fluxos do paciente, oportunizando a análise crítica de todas as etapas para a busca da redução dos desperdícios existentes. / In search of the general improvement of health care organizations in different countries are adopting Lean Thinking. this method consists of a systematic approach to identifying and eliminating waste in production processes, while it has its main focus on adding quality and deliver to the customer only what he sees as value. OBJECTIVE: To identify the different types of existing waste and suggestions for improvements in the emergency department of a private hospital in Caxias do Sul, Rio Grande do Sul, Brazil. METHODS: This is a case study with a qualitative approach, performed in an emergency department a hospital in the city of Caxias do Sul the study sample consisted of 14 professionals working in the emergency department, and 68 flows care of patients. Data collection was conducted observation of workflows associated with conducting focus group. Quantitative data were analyzed using descriptive statistics and qualitative data through content analysis. RESULTS: of the eight types of waste covered by the methodology Lean Thinking, we identified the existence of seven of these, which were wasted by waiting, unnecessary transport and handling, inventory, unnecessary, inappropriate processing, defects and waste of human potential. CONCLUSION: The application of Lean Thinking in the emergency department facilitated the determination of what is actually added value to the service user. Undoubtedly methodology facilitates the visualization of processes and work flows of the patient, providing opportunities for critical analysis of all the steps to search for existing waste reduction.

Submitted by Filipe dos Santos (fsantos@pucsp.br) on 2017-07-28T12:37:48Z No. of bitstreams: 1 Clara Kislanov da Costa.pdf: 825858 bytes, checksum: 0c59c010044af05cc25c4d1444454bd3 (MD5) / Made available in DSpace on 2017-07-28T12:37:48Z (GMT). No. of bitstreams: 1 Clara Kislanov da Costa.pdf: 825858 bytes, checksum: 0c59c010044af05cc25c4d1444454bd3 (MD5) Previous issue date: 2017-07-21 / Conselho Nacional de Pesquisa e Desenvolvimento Científico e Tecnológico - CNPq / The presence of the psychoanalyst in the hospital’s emergency room still raises questions about what this professional is capable of doing in such place. The main goal of this research is to understand what is the role of the psychoanalyst in the emergency service, given the hurdles he/she can find due to a different look and a specific sense of ethics in this environment. To achieve this goal, a qualitative research was carried out, based on a theoretical discussion and a psychoanalytical reading which, in its turn, originated from the researcher experience and also from interviews with professionals from the field of Psychology. Authors like Freud, Winnicott and Roussillon were mentioned in order to give a better understanding to the main topics researched, such as the emergence of anguish, the avoidance of the traumatic and the possibilities of symbolization. In addition, this research also intends to show the importance of a care and listening that are not necessarily exclusive to the psychoanalyst. This knowledge may be used by other professionals who work in emergency units in benefit of the patient and his/her relatives / A presença do psicanalista no pronto-socorro hospitalar ainda suscita indagações acerca do que pode fazer tal profissional nesse local. Este estudo busca compreender quais são as possibilidades de atuação para o psicanalista em um serviço de urgência e emergência, considerando-se os impasses que esse profissional poderá encontrar nesse ambiente ao trabalhar segundo uma ética e olhar específicos. Trata-se de pesquisa qualitativa fundamentada em uma reflexão teórica realizada a partir de uma leitura psicanalítica e que teve como base empírica vinhetas originárias de experiências da pesquisadora e de profissionais de Psicologia entrevistados. Autores como Freud, Winnicott e Roussillon são utilizados para a compreensão de temas caros à pesquisa, tais como a emergência da angústia, a evitação do traumático e as possibilidades de simbolização. Visa-se ainda contribuir para a valorização de uma escuta e cuidado que não são necessariamente exclusivos do psicanalista. Dessa forma, podem ser utilizados também pelos demais profissionais que trabalham em prontos-socorros em prol do paciente e de seu familiar

Bakgrund: Att vara illamående påverkar människan negativt och den som upplever illamående känner ofta samtidigt ett lidande. Ett av sjuksköterskans grundläggande arbeten är att lindra lidande och främja hälsa. För att på bästa sätt kunna lindra lidande behöver ambulanssjuksköterskan behärska både sina vårdvetenskapliga och medicinska kunskaper. Illamående inom ambulanssjukvården är ett relativt outforskat område som förtjänar ett större fokus. Syfte: Studiens syfte var att kartlägga förekomsten av illamående hos patienter inom ambulanssjukvården samt om faktorer som kön, ålder, vårdtid i ambulans och mottagande klinik relaterat till sjukdomstillstånd utgör skillnader i förekomsten av illamående. Metod: Undersökningen genomfördes som en retrospektiv journalgranskning med en kvantitativ ansats där 362 journaler granskades. Även demografisk data och farmakologisk behandling med antiemetika registrerades. Resultatet analyserades och hypotesprövningar genomfördes med chitvåtest. Resultat: Studien visade att 17,1% av patienterna var illamående, 17,4% var inte illamående och dokumentation om illamående saknades i 65,5% av journalerna. Patienter som led av kirurgiska tillstånd upplevde mer illamående jämfört med patienter med ortopediska eller medicinska tillstånd, p = 0,0303. En tendens till mer illamående hos kvinnor än män kunde tydas, liksom hos yngre jämfört med äldre. Det fanns även en trend till att illamåendet ökade vid längre vårdtider i ambulansen. Totalt 40,3% av patienterna som upplevde illamående behandlades med antiemetika. Slutsats: Studien visade att både dokumentation om illamående i ambulansjournaler och behandling av illamående var otillräcklig. Det fanns ett samband mellan mottagande klinik och frekvensen av illamående, där patienter med kirurgiska tillstånd upplevde mest illamående. Vidare forskning om avsaknad av dokumentation av illamående och vilka faktorer som påverkar förekomsten av illamående skulle kunna leda till en utveckling av behandlingsriktlinjer och beslutstöd inom ambulanssjukvården. / Background: Nausea is an unpleasant sensation that can cause considerable suffering. One important task for nurses is to relieve suffering and promote wellbeing. In order to relieve suffering paramedics need to be proficient in both medical and caring skills.  Nausea amongst patients within the ambulance service is a relatively sparsely researched field that deserves a greater focus. Aim: To examine the prevalence of nausea amongst patients within the ambulance service and whether the prevalence is affected by factors such as gender, age, time in the ambulance or clinic. Method: In this study 362 ambulance journals from a Southern region in Sweden were examined retrospectively for documentation of nausea. Demographic data and treatment with antiemetics were also recorded. Statistical analysis of significance levels was performed using the Chi-squared test. Results: In 17.1% of cases the patient suffered from nausea and in 17.4% there was documentation that the patient was not nauseous, while there was a lack of documentation in 65.5% of the journals. A significantly larger proportion of patients with surgical conditions suffered from nausea than those with medical or orthopaedic conditions (p = 0.0303). The prevalence of nausea was slightly greater for women than men and for patients under age 60 than over age 60 and there was a trend towards more nausea the longer the time in the ambulance was. Only 40.3% of those who reported nausea were given antiemetics Conclusions: The study showed that both documentation and treatment of nausea were inadequate. There was a connection between which hospital clinic the patients were handed over to and the frequency of nausea, with surgical patients showing the most nausea. Further studies are needed to investigate the lack of documentation of nausea within the ambulance service and factors influencing the prevalence of nausea. This could lead to a predictive instrument to help paramedics detect nausea and better protocols for treating and helping to alleviate nausea.

This thesis is focused on the detection of the effectiveness of the established information system that is used by the Emergency Medical Service of the Vysočina Region to keep medical records; in case of the Emergency Medical Assistance there are used intervention records. The aim of this thesis is to determine the effectiveness of information system implementation used for the administration of medical records on the basis of selected indicators. This research will confirm or refute hypotheses whether keeping of medical records in electronic form is effective for the organization in terms of potential time savings, or from the perspective of the administration of medical records. This thesis is to introduce a comprehensive view on the matters of computerization of medical records, namely in a specific environment of the Emergency Medical Service. The introduction describes terms that are used in this thesis. There is defined the environment of the Emergency Medical Service, specified the documentation and forms of the medical records administration which is used by the Emergency Medical Service. There is also introduced the information system that serves the medical records administration and the theory of cost effectiveness. The practical part is focused on the analysis of the information system, and on confirmation and refutation of set hypotheses supported by quantitative research. The summary and recommendation are based on obtained and analyzed results of this research.

Os efeitos do trauma no organismo do idoso são sistêmicos e as complicações são comuns, o que pode resultar em aumento do tempo de hospitalização e maior número de mortes. Conhecer as características específicas deste evento para o idoso pode auxiliar os enfermeiros na tomada de decisões no atendimento pré-hospitalar móvel avançado. Os objetivos deste estudo foram analisar as evidências disponíveis na literatura científica acerca das intervenções de enfermagem no atendimento pré-hospitalar móvel para idosos pós-trauma e construir um protocolo assistencial de enfermagem para o atendimento pré-hospitalar móvel avançado de idosos pós-trauma. A pesquisa foi conduzida em duas fases: revisão integrativa e estudo metodológico e descritivo. A busca dos estudos primários foi realizada nas bases de dados PubMed, CINAHL e LILACS. A amostra da revisão integrativa foi composta por 26 estudos, agrupados em seis categorias temáticas, a saber: intervenções de enfermagem: circulação com controle da hemorragia (n=11); intervenções de enfermagem: disfunção, estado neurológico (n=7); intervenções de enfermagem: via aérea com proteção da coluna cervical (n=3); intervenções de enfermagem: avaliação secundária (n=3); intervenções de enfermagem: ventilação e respiração (n=1) e intervenções de enfermagem: exposição\\controle do ambiente (n=1). Em relação à construção do protocolo assistencial de enfermagem, as evidências encontradas na literatura e as recomendações de dois programas e duas diretrizes de atendimento ao trauma contribuíram para sua construção. O protocolo assistencial de enfermagem foi estruturado contendo título, objetivo, intervenções de enfermagem, atividades de enfermagem e suas respetivas justificativas, com ênfase na avaliação primária e secundária do atendimento ao trauma e reuniu de forma organizada as especificidades da senescência e senilidade. As evidências levantadas na literatura contribuíram para a elaboração do protocolo assistencial de enfermagem, que poderá subsidiar o atendimento imediato e avançado ao idoso pós-trauma / The effects of a trauma in the organism of elderly individuals are systemic and complications are common, which may result in longer hospitalizations and a greater number of deaths. Being aware of the specificities of this event among elderly individuals can aid the decision-making of nurses when providing advanced prehospital care in a mobile unit. This study\'s objective were to analyze evidence available in the scientific literature addressing nursing interventions provided to elderly individuals in prehospital care provided in mobile units after a trauma and develop a nursing protocol for elderly trauma patients specific for advanced prehospital care provided in mobile units. The study was conducted in two phases: integrative review and methodological and descriptive study. Primary studies were searched in the PubMed, CINAHL and LILACS databases. The sample for the integrative review was composed of 26 studies grouped into six thematic categories, namely: nursing interventions: circulation with hemorrhage control (n=11); nursing interventions: disorder, neurological status (n=7); nursing interventions: cervical spine protection in airway management (n=3); nursing interventions: secondary assessment (n=3); nursing interventions: ventilation and respiration (n=1); and nursing interventions: exposure/environment control (n=1). Evidence found in the literature and recommendations from two programs and two guidelines for essential trauma care contributed to the development of this nursing care protocol. The nursing care protocol was structured with a title, objective, nursing interventions, nursing activities, and respective justifications, with an emphasis on primary and secondary assessment of trauma care, and organized the specificities of senescence and senility. Evidence found in the literature contributed to develop a nursing care protocol that can support the immediate and advanced care provided to elderly patients after a trauma

INTRODUÇÃO: A doença diarreica aguda é a segunda causa de morte em crianças abaixo de 5 anos de idade. No Brasil, entre 2003 e 2009, a diarreia aguda foi responsável por cerca de 100.000 internações por ano, e por 4% das mortes em crianças abaixo de 5 anos de idade. O rotavírus é a principal etiologia de diarreia aguda grave no mundo todo, sendo responsável por 40% das internações por diarreia aguda, e 29% de todas as mortes por diarreia aguda. A vacina monovalente (RV1) contra o rotavírus foi introduzida no Programa Nacional de Imunizações em 2006. OBJETIVOS: Verificar o impacto da vacina monovalente contra rotavírus nas consultas de pronto-socorro e internações por doença diarreica aguda em crianças menores de 5 anos de idade, verificar a positividade do exame \"pesquisa de rotavírus nas fezes\", e verificar a presença ao ausência de imunidade de rebanho. METODOLOGIA: Foi realizado um estudo ecológico retrospectivo no Hospital Universitário da Universidade de São Paulo. O período foi dividido em pré-vacina (2003 a 2005) e pós-vacina (2007 a 2009). Foram incluídas todas as crianças abaixo de 5 anos que passaram em consulta no pronto-socorro e verificado o diagnóstico do atendimento e internação através de registro eletrônico. Foram obtidas as taxas de consultas no pronto-socorro e internações por doença diarreica aguda, foram selecionadas as crianças não vacinadas para cálculo da imunidade de rebanho, e verificado se houve coleta do exame pesquisa de rotavírus nas fezes. A redução nas taxas foi obtida através da fórmula: redução (%) = (1 - odds ratio) x 100. RESULTADOS: No período pré-vacina a taxa de consultas por diarreia aguda foi de 85,8 consultas por 1.000 consultas gerais, no período pós vacina a taxa de consultas por diarreia aguda foi 80,9 por 1.000, e a redução foi 6% (IC 95%, 4% a 9%, p < 0,001), chegando a 40% (IC 95%, 36% a 44%, p<0,001) nos meses de maio e junho. A taxa de internação por diarreia aguda era 40,8 internações por 1.000 e caiu para 24,9 por 1.000, redução de 40% (IC 95%, 22% a 54%, p < 0,001), chegando a 82% (IC 95%, 62% a 92%, p < 0,001) nos meses de maio e junho. Nas crianças não vacinadas não houve redução na taxa de consultas de pronto-socorro (IC 95%, -4% a 5%, p=0,903), e não se pode afirmar se houve redução ou aumento das internações por diarreia aguda (IC 95%, -212% a 35%, p=0,381). Houve queda da positividade do exame pesquisa de rotavírus em 2009 (redução de 70%, IC 95%, 26% a 88%, p=0,007). CONCLUSÕES: Após a introdução da vacina contra rotavírus (RV1) houve uma redução de 6% nas consultas por diarreia aguda no pronto-socorro, de 40% nas internações por diarreia aguda e de 70% na positividade do exame pesquisa de rotavírus nas fezes. Não foi detectada imunidade de rebanho / INTRODUCTION: Acute diarrheal disease is the second cause of death in children under five years. In Brazil, from 2003 to 2009, acute diarrhea was responsible for nearly 100,000 deaths per year and 4% of the deaths in children under five years. Rotavirus is the leading cause of severe acute diarrhea worldwide, accounting for 40% of hospital admissions and 29% of all the acute diarrhea-related deaths. In 2006, the rotavirus monovalent vaccine (RV1) was added to the Brazilian National Immunization Program. OBJECTIVES: To analyze the impact of the RV1 on Emergency Department (ED) visits and hospital admissions for acute diarrhea, the rates of positivity of the stool rotavirus tests and the presence or absence of herd immunity. METHODS: A retrospective ecologic study at the University Hospital, University of Sao Paulo. The study analyzed two periods: the pre-vaccine (2003-2005) and the post-vaccine (2007-2009) periods. We screened the main diagnosis of all ED attendances and hospital admissions of children under five years in an electronic registry system database and calculated the rates of ED visits, hospital admissions and positivity of the stool rotavirus test in patients with acute diarrhea. Herd immunization was evaluated in non-vaccinated children. The reduction rate was analyzed according to the formula: reduction (%) = (1- odds ratio) x 100. RESULTS: The rates of ED visits for acute diarrhea was 85.8 and and 80.9 per 1,000 total ED visits in the pre and post vaccination periods, respectively, resulting in 6% reduction (95% CI, 4% to 9%, p< 0.001) in the overall period and reaching 40% reduction on May and June. The rates of hospital admissions for acute diarrhea was 40.8 per 1,000 in the pre-vaccine period and dropped to 24.9 per 1,000 hospitalizations, resulting in 40% reduction (95% CI, 22% to 54%, p < 0.001) in the overall period and 82% (95% CI, 62% to 92%, p < 0.001) on May and June. Among non-vaccinated children, no reduction on ED visits was observed (95% CI, -4% to 5%, p=0.903), while an increase or reduction in the hospitalization rates could not be determined (95% CI, -212% to 35%, p=0.381). There was a decrease in the positivity of the stool rotavirus tests in 2009 (70% reduction, 95% CI, 26% to 88%, p=0.007). CONCLUSIONS: The introduction of the RV1 vaccine resulted in 6% reduction in the ED visits and 40% reduction in hospital admissions for acute diarrhea, and 70% reduction in the rates of positive stool rotavirus tests. No herd immunity was observed

The United States is experiencing a severe shortage of Emergency Medical Service (EMS) paramedics. The job outlook for paramedics (EMT-P) for the years 2012-2022 is predicted to increase by 23%-33%, which is much faster than the 4% average increase of other first-response professions. The average tenure of paramedics is less than 4 years. There is a significant gap in the literature concerning paramedic personality traits and tenure. The primary objective of the current study is to provide empirical data on the personality traits possessed by long-term paramedics (5+ years), and compare them to those with shorter tenure (< 5 years). Using Allport's Trait Theory, I predicted that personality would affect paramedic longevity. The 6 personality traits tested were warmth, reasoning, emotional stability, liveliness, social boldness and openness to change. A socio-demographic questionnaire, determined the length of their EMS career, while the 16PF® Assessment, tested their personality traits. Using t tests, Mann-Whitney U tests, and a set of regression analyses, data were examined to determine if length of career and personality traits predicted paramedic tenure. The research sample consisted of long term paramedics and former paramedics. The results showed that of the 6 personality traits, only warmth was a significant predictor of paramedic tenure. A logistic regression showed for every additional point in warmth, the odds of leaving EMS prior to 5 years increased by a factor of 2.77. This study provides support for positive social change by helping EMS to learn how to increase recruitment and tenure. It also helps by advising EMS agencies to attend to the mental and emotional health of their paramedics by being aware of the level of their warmth personality trait.

The primary aim of the research project was to develop conceptual models of rural ambulance service delivery based on different worldviews or philosophical positions, and then to compare and contrast these new and emerging models with existing organisational policy and practice. Four research aims were explored: community expectations of pre-hospital care, the existing organization of rural ambulance services, the measurement of ambulance service performance, and the comparative suitability of different pre-hospital models of service delivery. A unique feature was the use of soft systems methodology to develop the models of service delivery. It is one of the major non-traditional systems approaches to organisational research and lends itself to problem solving in the real world. The classic literature-hypothesis-experiment-results-conclusion model of research was not followed. Instead, policy and political analysis techniques were used as counter-points to the systems approach. The program of research employed a triangulation technique to adduce evidence from various sources in order to analyse ambulance services in rural Victoria. In particular, information from questionnaires, a focus group, interviews and performance data from the ambulance services themselves were used. These formed a rich dataset that provided new insight into rural ambulance services. Five service delivery models based on different worldviews were developed, each with its own characteristics, transformation processes and performance criteria. The models developed are titled: competitive; sufficing; community; expert; and practitioner. These conceptual models are presented as metaphors and in the form of holons and rich pictures, and then transformed into patient pathways for operational implementation. All five conceptual models meet the criteria for systemic desirability and were assessed for their political and cultural feasibility in a range of different rural communities. They provide a solid foundation for future discourse, debate and discussion about possible changes to the way pre-hospital services are delivered in rural Victoria.

The emergency medical services (EMS) provide the preliminary assistance and transportation for patients in need of urgent medical care in order to decrease the mortality rate and reduce the non-reversible effects of injuries. Since the objective is directly related to the human life, the value of the proposed solutions in order to improve the performance of EMS is highly welcomed. Mainly, there are three problems that EMS managers face with: location, allocation and redeployment of the EMS facilities/vehicles. Most of the studies in EMS literature focus on accurately modeling the probabilistic nature of the availability of an ambulance when it is called for. However, trivial changes in model parameters or estimates could dramatically change the optimal allocations generated by the probabilistic models and hence make the model invalid. In this study, we formulate the ambulance location problem as a deterministic multi-level maximal coverage model by which the total demand is tried to be covered as many as possible at multiple levels. Both a mathematical programming model and genetic algorithm-based heuristic approaches are proposed for the problem. The results indicate that the genetic algorithm-based solutions give reliable (near-optimal) and robust results in reasonable computational times for the problem. Moreover, the tradeoffs between the two performance measures, &lsquo / responsiveness&rsquo / and &lsquo / preparedness&rsquo / , are searched for / and our approaches with multi-level coverage are compared against the multiple coverage approaches in terms of these performance measures.