A superlotação de serviços de emergência é problema sério e de grande relevância do sistema de saúde, não sendo restrito ao nosso meio. Os estudos que enfocam esse tema vêm tomando proporções na literatura internacional. O que se vem vivenciando há mais de uma década são prontos socorros lotados devido a um deslocamento da população em direção a estes serviços, configurando-os como prestadores de atenção primária de assistência à saúde e, não de fato, destinados ao atendimento de emergências. O principal objetivo do estudo foi recompor a trajetória do usuário do serviço de saúde até a chegada à unidade de emergência de um hospital terciário do município, qualificando-o segundo as razões de escolha de atendimento e caracterizando seu perfil socioeconômico e demográfico. Este estudo de corte transversal se restringiu à análise da demanda espontânea do Pronto Socorro de Emergências Clínicas do Hospital das Clínicas da Universidade de São Paulo. Foram entrevistados todos os usuários que procuraram este serviço durante uma semana típica. Dos pacientes entrevistados, foram incluídos no estudo 881 pacientes, o que representou 93,1% do total. Realizada a análise estatística univariada, seguida pela construção de um modelo de regressão logística, para estudo das variáveis associadas à vinda direta ao pronto socorro. Os resultados demonstraram que a demanda era constituída predominantemente de mulheres, brancas, com idade média de 44 anos, baixo grau de instrução, com rendimento per capita mensal de até uns salários mínimos e residentes no município de São Paulo (81,3%). Cinco por cento tinham direito à assistência médica privada. Quanto ao acesso a serviços de saúde, 72,5% residiam próximo a serviços de saúde de atenção primária e 53,4% a hospitais e/ou prontos socorros. Quanto à trajetória percorrida antes da chegada ao pronto socorro, 56,2% procuraram diretamente o pronto socorro. Dos pacientes que procuraram outros serviços previamente, 26,4% passaram por unidades básicas de saúde e 73,6% por outros hospitais/prontos socorros. Dos 881 pacientes entrevistados, 771 foram dispensados após consulta médica. As características associadas à vinda direta ao pronto socorro foram: nível superior de escolaridade, não ser casado, não ter diagnóstico médico, possuir cartão do Hospital das Clínicas, ter idade entre 25 e 39 anos e contribuir para a Previdência Social. Por outro lado, quanto maior a duração da queixa e quanto mais distante o local de residência, menor a probabilidade de procurar este serviço diretamente. As razões do uso dos serviços de emergência envolvem mecanismos complexos, além da credibilidade e confiança na instituição, facilidade de acesso e baixa resolutividade dos outros serviços da rede pública de saúde. Contrariamente ao senso comum e a visão corrente de vários gestores do sistema de saúde, a problemática de superlotação dos serviços de emergência não reside apenas na atenção primária, mas sim no baixo poder de resolução da rede hospitalar. / Overcrowding in Emergency Department is a Public Health problem not only in Brazil. However, information about the population that search for emergency medical care at tertiary hospitals in Brazil is incomplete. Therefore, the main objective of this work was to reconstruct the pathway of these patients until their arrival to the Clinical Emergency Department of a tertiary Hospital. During a typical week, 1121 patients were attended at the Hospital das Clínicas Clinical Emergency Department, São Paulo, Brazil. From this total, 946 were interviewed and 881 (93,1%) were selected to the study. The selected patients were questioned by health care professionals before the medical consult, regarding their demographic characterization, as well as questions about the reasons why they choose this specific health service. Variables associated to the patients coming to the hospital were studied by univariate analysis followed by construction of a logistic regression model. The emergency service demand is composed predominantly by white women, 44 years old (mean age), living in São Paulo City (81,3%), low instruction grade, monthly income around US$ 80. Only 5% of them have private health care plan. Usually they have a primary medical service (72,5%) or a hospital/emergency service (53,4%)in their home neighborhoods. More than half of the patients (56,2%) came directly to the Clinical Emergency Department, without searching for a less complex service. The most frequent diagnosis was upper airways infections. More than 92% of the patients attended were discharged after a simple medical consultation, suggesting that they could have been seen in a less complex health care facility. Patients not married, aged between 25 and 39 years old, with higher level of instruction, without clinical disease and that had been attended at Hospital das Clínicas any time were more likely to search this emergency service before to go to other health services. In other hand, patients living far from the service and with symptoms during several days were less likely to search this service directly. Asked the reasons they search this specific Emergency Service, patients cited credibility and trust are major factors, along with lack of confidence and solving ability of the others services. Factors priming the patients to have this specific service as a first choice were living close to the Hospital, higher education level, symptoms lasting less than one day and fever as a presenting symptom. From the patients attended in other services, prior to their arrival at this Emergency Department, 26,4% were seen at primary care facilities and 73,6% at other hospitals. In this study we have shown that the reasons why patients search for a Clinical Emergency Department in a tertiary Hospital is very complex, including easy access, credibility and lack of trust in other services. These results are contrary to the common sense, and the current view of Health Care directors. Overcrowding in Emergency Departments is due not only to inefficiency Primary Care services, but also to low solving ability of hospital services.

Varje år drabbas 30 000 svenskar av stroke, vilket innebär stora personliga omställningar och stora kostnader för samhället. Den mest effektiva behandlingen, trombolys, måste ges så snart som möjligt för att ha god effekt.  Samtidigt som det är av största vikt att ta reda på om patienten har några differentialdiagnoser som gör behandlingen riskfylld. Den här studien undersöker hur strokekedjan går till och vilka faktorer som påverkar beslutsfattandet. Studien är baserad på etnografiska fältstudier på fyra svenska sjukhus och materialet är analyserat med metoder från sammansatta kognitiva system och målorienterad design. Resultaten visar att trots olika organiserade strokekedjor på de olika sjukhusen är processerna desamma och direkt kommunikation är mest framgångsrik för att effektivt sprida information mellan dem. Neurologjouren är viktig roll som, liksom resten av aktörerna i strokekedjan, ständigt balanserar sitt beslutsfattande mellan effektivitet och grundlighet. Kombinationen av analyser ger resultat både på system- och individnivå. Möjligheter för förbättrade strokekedjor ges i termer av logistiska, tekniska och organisatoriska förslag. / 30 000 people in Sweden get a stroke every year. This leads to large personal adaptions as well as high costs for the society. The most efficient treatment, thrombolysis, must be given as soon as possible to have a good effect. At the same time it is very important to find out if the patient has any differential diagnosis that can make the treatment hazardous. This study investigates how the course ov events around acute stroke patients take place and important factors for the decision making. The studiy is based on ethnographic field studys on four swedish hospitals. The material is analysed with methods from joint cognitive systems and goal-oriented design. The results show that in spite of different organisation of the course  of events around acute stroke patients are the processes and direct communication most successful for effective spread of information between the processes. The neurologist on call is an important roll who, as well as the rest of the participants in the course of events, balances the decision making between efficiency and thoroughness. The combination of analysis gives results on both system- and individual levels. Possibilites for improvents are given in three categories: logistic, technological and organizational.

This diploma thesis deals with the construction project of the outbound base of the emergency medical service in Zabreh na Morave. More specifically, this thesis deals with the study of the development of the building, the technological regulation for the flat roof, and the subsequent chapters - design and assessment of the lifting mechanism, optimal design of the building site, timetable, itemized budget, control and test plan, etc. An interesting point is the simulation of the construction, where a 3D model and a video are created. The thesis is based on a borrowed documentation of the project.