CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / Este estudo, descritivo, teve como objetivo elaborar uma proposta para organizaÃÃo do Sistema Estadual de UrgÃncia e EmergÃncia no estado do CearÃ-Brasil, baseado na implantaÃÃo de serviÃos de atendimento prÃ-hospitalar de urgÃncia e emergÃncia. PropÃe o desenho de regionalizaÃÃo dos serviÃos na Ãtica do atendimento prÃ-hospitalar com Ãnfase na integralidade da atenÃÃo e integraÃÃo dos serviÃos, da qualificaÃÃo e da humanizaÃÃo da atenÃÃo. Com base nos dados do Datasus, e IBGE, ano 2003 e de acordo com o estabelecido pela Portaria GM-MS 2048/2003, foram definidos 12 pÃlos regionais de urgÃncia e emergÃncia com o mesmo nÃmero de centrais de regulaÃÃo (11 a serem implantadas). SÃo necessÃrias 133 ambulÃncias de suporte bÃsico (USB) e 28 ambulÃncias de suporte avanÃado (USA). O pessoal necessÃrio serÃ: 396 mÃdicos, 396 enfermeiros, 737 auxiliares/tÃcnico de enfermagem, 660 condutores socorristas, 11 farmacÃuticos, 110 telefonistas, entre outros. Foi analisado o quantitativo de internaÃÃes realizadas nos 20 hospitais pÃlos em relaÃÃo a intervalos de distÃncia do local da residÃncia. A ocupaÃÃo dos leitos à em sua maioria feita pelos residentes dos municÃpios onde o hospital està localizado. Com base nos parÃmetros do Ato Portaria n 1101/GM-MS e de acordo com o agrupamento pÃlo-regional sugerido foi analisado o quantitativo de leitos disponÃveis, verificou-se que o nÃmero de leitos à insuficiente, sendo mais preocupante a situaÃÃo dos leitos de UTI. Quanto aos tipos de procedimentos de urgÃncia e emergÃncia, na comparaÃÃo entre os pÃlos, por freqÃÃncia, existe maior concentraÃÃo nas internaÃÃes para realizaÃÃo de partos, cesarianas e curetagem pÃs-aborto. Sugere-se que a implantaÃÃo seja feita de forma gradual com prioridade para as regiÃes mais desassistidas. Na repactuaÃÃo da ocupaÃÃo dos leitos dos hospitais pÃlo-regionais deverà haver definiÃÃo clara de um percentual eqÃitativo para os tipos de procedimentos por internaÃÃo a serem utilizados pelos moradores dos municÃpios da Ãrea de cobertura regional, com definiÃÃo de um âportfÃlioâ padronizado de serviÃos hospitalares, almejando auto-suficiÃncia do atendimento de urgÃncia e emergÃncia a nÃvel micro e macrorregional de saÃde no estado do CearÃ. / This study, descriptive, aimed to develop a proposal for organizing the State System of Urgency and Emergency in the state of CearÃ-Brazil, based on the deployment of the prehospital emergency care. Proposes the design of regional services in the optics of prehospital care with emphasis on the completeness of care and integration of services, qualification and the humanization of attention. Based on data from DATASUS and IBGE, year 2003, in conformity with a Minister of Health Order n 2048/2003-GM-MS, were defined 12 regional clusters of urgency/emergency, with the same number of centrals regulation (11 to be implanted), 133 ambulances are needed for basic support (USB in portuguese) and 28 ambulances for advanced support (USA in portuguese). The necessary staff will be: 396 physicians, 396 nurses, 737 assistant/technical nursing, 660 ambulance drivers, 11 pharmacists, 110 telephone operators, among others. It was analyzed the admissions quantitative made in 20 poles hospitals in relation to the intervals of distance from the place of domicile. The occupation of beds is, in its majority, made by people of the municipality where the hospital is located. Based on the features of the Act Order of a Minister of Health n 1101/GM-MS and according to the pole-regional grouping suggested, an analysis was made to verify the amount of beds available. It was obeyed that the number of beds is insufficient, more worrying is the situation of the ICU beds. As for the types of procedures of emergency, in the comparison between the poles, by frequency, there is greater focus on admissions for carrying out deliveries, cesarean sections and curettage post-abortion. It is suggested that the implementation of services should be done gradually with priority to the most underprivileged regions. In the re agreement of occupation of the beds in poleregional hospitals there should be clear a fair percentage for the types of procedures to be used by residents of the municipalities in regional coverage area, with definition of a standardized portfolio of hospital services, targeting self-sufficiency of emergency care at micro and macrorregional health in the state of Ceara.

Critical Incident Stress (CIS) in emergency workers and in victims of crises is widely held to be the possible precursor to Post Traumatic Stress Disorder (PTSD) if left unattended. Indeed, the symptoms for CIS and PTSD overlap in all category areas. Today, the commonly used treatment for trauma in emergency workers is Critical Incident Stress Management (CISM). This system of interventions includes a debriefing session which facilitates people to fully remember the trauma events and their own reactions to it. CISM models were conceived and designed within and from a typically white, western viewpoint. However, one agency in Vancouver, First Nations Emergency Services Society (FNESS), provides CISM debriefing interventions and training to Native emergency workers and Native victims of crises. The purpose of this study was to document how Native participants perceived the CISM model as FNESS presented it and to understand whether the intervention was culturally meaningful for the First Nations participants in the CISM sessions. This study examined whether the mainstream CISM model, which is currently used by this agency, is culturally meaningful for populations of another culture receiving it. Narrative interviews were conducted with participants to determine their reactions to the session, their feelings regarding information presented, and their ability to make cultural meaning of the experience. Narrative analysis was used to determine themes across individuals. Theoretical implications of this research include addressing the gap in the literature of the subjective experiences of participants in CISM; no studies have used a purely qualitative methodology to study this topic. Also, this study looked at the important issue of the cross-cultural application of a mainstream intervention, particularly for a population with a history of complex traumas. Practical implications include providing information into the perceived effectiveness of the FNESS approach to a CISM framework and providing an opportunity for recipients' opinions to be heard. / Education, Faculty of / Educational and Counselling Psychology, and Special Education (ECPS), Department of / Graduate

This thesis is a case analysis of the nature of delays in emergency room admissions and the effects on ambulance dispatching and availability as it occurred in Southern California.

The diploma thesis deals with a case of cross-border cooperation in the European Union, namely the cross-border cooperation of health emergency services in the Šumava Euroregion. The research focuses mainly on how this cooperation has been arranged and how the European integration theory can be applied to this case study. The diploma thesis analyzes the role of different actors, what contracts were needed for the cross-border cooperation, how the negotiationof the project took place, where the initiative for this cross-border cooperation originated or what complications occurred. The topic of cross-border cooperation of health emergency services is a practical example of European integration and therefore it also includes the study of cross-border cooperation of regions in the European Union, the role of EU funds for regional development and last but not least the EU health policy. The thesis is based on the theory of European territorial integration, which is characterized by the disappearance of the border and suppression of the unilateral orientation of the state inland. Furthermore, there are related theories of regional development and new regionalism. It also works with the theory of shared sovereignty, which inevitably comes with deeper integration. The theme of the diploma theses is time...

Human enhancement (HE) is the field of research aiming to improve and overcome the biological limitations of the physical and mental performance of humans. The implications of HE might especially prove relevant within high-intensity environments, such as the working environment of police and fire and rescue services. The aim of this thesis is to identify the needs of personnel within these domains and to highlight potential HE solutions that could aid to improve responder performance in the setting of an active emergency. Interviews conducted with representatives for the Swedish police and fire and rescue service highlighted the need for support of mental performance in the form of destressing during highintensity situations as well as an improvement of creating situational awareness and making adequate decisions in a short amount of time. The results imply a potential of implementing HE solutions that aid emergency responders by keeping them alert and open for information gathering or minimizing the experienced level of stress while providing vital information for a proper response. The thesis alsoconcluded a generally positive attitude towards implementation of HE solutions.

This dissertation consists of three essays in health economics concerned with measuring the determinants of health care resource utilization and health. In the first chapter, I study entry barriers in healthcare provider markets. In the U.S., proponents of regulatory entry barriers called CON programs claim that they reduce waste by limiting "unnecessary" entry. I examine CON programs in the dialysis industry, where their effects on market structure, access, health, costs, and welfare are poorly understood, and where patients are sensitive to access and quality. I combine quasi-experimental policy variation in low population areas with a structural model of patient preferences to find that marginal entrants improved access significantly, reduced hospitalization rates, and generated for patients the utility value of traveling 275-344 fewer miles per month; but there is evidence that they contributed even more to fixed costs. Using policy variation throughout North Carolina, I also find evidence that the NC dialysis CON program created a mechanism through which incumbents could block potential entrants by expanding in tandem with their local patient populations. Taken together, my findings suggest that stronger regulatory entry barriers in low population areas may raise total welfare at patients' expense---but they also amplify concerns that CON programs dampen competition statewide. In the second chapter, I study an empirical framework commonly used in health economics research to measure the impact of an event over time using observational data: the event study. Dating back to at least Snow (1855), event studies have been used in health economics research to study mortality, health care utilization, health insurance enrollment, provider competition, and much more. Under no anticipation and parallel trends assumptions, difference-in-differences are known to identify the event's average treatment effect on the treated when units experience one event at most. In this paper, I introduce a new event study framework to accommodate settings where units may experience multiple events. I introduce a matching estimator which consistently and transparently estimates the average treatment effect on the treated of a single event under generalizations of the conventional no anticipation and parallel trends assumptions. I show that the matching estimator is equivalent to a weighted least squares estimator for a particular set of weights. I also introduce a parallel pre-trends test which can be used to scrutinize these assumptions in the usual sense. Finally, I demonstrate in a series of Monte Carlo simulations that the estimator and parallel pre-trends test work well for a wide range of treatment effects, including dynamic, non-stationary, and history-dependent treatment effects. In the third chapter, I study when and why emergency departments initiate ambulance diversions, and what happens to diverted patients. Efficiently distributing scarce healthcare resources among patients with time sensitive healthcare needs and uncertain arrival rates is a hard problem. When an emergency department gets too full, ED managers sometimes request that incoming ambulances reroute their patients to alternative destinations. While such ambulance diversions can sometimes help an overcrowded ED manage its caseload, it can also harm incoming patients and reduce systemwide EMS responsiveness. In detailed administrative records cataloging when, where, and why diversions occur, as well as who got diverted, I document that diversions commonly last exactly 1 hour, approximately 4 hours, and exactly 8 hours (indicating that managerial frictions may directly affect ED availability); that diverted patients have different characteristics than non-diverted patients (including potentially more severe symptoms); and that diverted patients spend 65% longer on the road to the hospital than non-diverted patients. I also find that diversions often occur not only because of crowdedness, but also because of hospital systems failures. I identify directions for future research.

Patient satisfaction dimensions have a wide ranging and significant impact on organizational performance in the healthcare industry. In addition, the Centers for Medicare and Medicaid Services Hospital Value Based Purchasing (HVBP) Program links patient satisfaction to Medicare reimbursement, putting millions of dollars at risk for health systems. A gap in the literature exists in the exploration of how a patient's experience in the emergency department affects their satisfaction with inpatient services. In a multiple regression analysis, the relationship between HVBP Patient Experience of Care and hospital level factors including emergency department wait times are explored. Results indicate a statistically significant relationship between hospital level factors and standardized measure of patient satisfaction with a moderate adjusted effect size (p= <.0001, R2 adjusted= 0.184). Emergency department wait times post physician admit orders were most salient in predicting patient satisfaction scores (rs2= 0.434, β= -0.334, p= <.001). Recommendations to improve emergency department wait times include focusing on key decision points and implementation of electronic systems to support the movement of admitted patients out of the emergency department as quickly as possible.

Titel: Ledarskap i ingripande- och utryckningsverksamhet Syfte: Vårt syfte med studien är att genom en inventering av ledarskap inom polis och räddningstjänst få en ökad förståelse för ledarskap i stressfulla situationer. Det för att möjliggöra en överföring av de lärdomar som polis och räddningstjänst besitter kring hantering av stress och stressfulla situationer till övriga mer traditionella yrken.  Metod: Vår studie präglas av en deduktiv forskningsansats och den forskningsmetod som använts är kvalitativ forskningsstrategi. Vid vår datainsamling använde vi oss av en fallstudie. Det gjordes genom intervjuer med respondenter besittande önskade kompetenser inom forskningsområdet.  Slutsats: Utifrån datainsamling har vi kommit fram till följande slutsatser:  *Ledarskapet växlar mellan detaljstyrt ledarskap och målinriktat ledarskap beroende på situation. *Vid stressfulla situationer är det viktigt att ledaren inte kastar sig in och deltar i situationens hetta. *Stresshantering är en avgörande faktor för framgång i ledarskap. *Tidsfaktorn är avgörande i beslutsfattande. *Tillit och förtroende är avgörande. / Title: Leadership in intervention and emergency services  Purpose: Our purpose with the study is to gain an increased understanding of leadership in stressful situations through an inventory of leadership in the police and emergency services. This is to enable the transfer of the knowledge that the police and emergency services possess about managing stress and stressful situations to other more traditional professions. Method: Our study is characterized by a deductive research approach and the research method that has been used is a qualitative research strategy. In our data collection we used a case study. This was completed by interviewing respondents with the desired competencies in the research area. Conclusion: Based on our data collection, we have reached the following conclusions: *Leadership alternates between detailed leadership and goal-oriented leadership depending on the situation. *In stressful situations, it is important that the leader does not dive into and participate in the heat of the situation. *Stress management is a crucial factor for success in leadership. *The time factor is crucial in decision making. *Trust and confidence are crucial.

Several calamities occur throughout the world each year, resulting in varying losses. Disasters wreak havoc on infrastructures and impair operation. They result in human deaths and injuries and stress people's mental and emotional states. These negative impacts of natural disasters induce significant economic losses, as demonstrated by the $ 423 billion loss in 2011 in Tohoku, Japan, and the $ 133 billion loss in hurricane Harvey, U.S.A. Every year, hurricanes and tropical storms result in 10,000 human deaths worldwide. To mitigate losses, communities' readiness, flexibility, and resilience must be strengthened. To this end, appropriate techniques for forecasting a community's capacity and functionality in the face of impending crises must be developed and suitable community resilience metrics and their quantification must be established. Collaboration between critical infrastructures such as power systems and emergency services and social networks is critical for building a resilient community. As a result, we require metrics that account for both the social and infrastructure aspects of the community. While the literature on critical infrastructures such as power systems discusses the effect of social factors on resilience, they do not model these social factors and metrics due to their complexity. On the other hand, it turns out that the role of critical infrastructures and some critical social characteristics is overlooked in the computational social science literature on community resilience. Thus, this dissertation presents a multi-agent socio-technical model of community resilience, taking into account the interconnection of power systems, emergency services, and social communities. We offer relevant measures for each section and describe dynamic change and its dependence on other metrics using a variety of theories and expertise from social science, psychology, electrical engineering, and emergency services. To validate the model, we used data on two hurricanes (Irma and Harvey) collected from Twitter, GoogleTrends, FEMA, power utilities, CNN, and Snopes (a fact-checking organization). We also describe methods for quantifying social metrics such as anxiety, risk perception, cooperation using social sensing, natural language processing, and text mining tools. / Doctor of Philosophy / Power systems serve social communities that consist of residential, commercial, and industrial customers. The social behavior and degree of collaboration of all stakeholders, such as consumers, prosumers, and utilities, affect the level of preparedness, mitigation, recovery, adaptability, and, thus, power system resilience. Nonetheless, the literature pays scant attention to stakeholders' social characteristics and collaborative efforts when confronted with a disaster and views the problem solely as a cyber-physical system. However, power system resilience, which is not a standalone discipline, is inherently a cyber-physical-social problem, making it complex to address. To this end, in this dissertation, we develop a socio-technical power system resilience model based on neuroscience, social science, and psychological theories and use the threshold model to simulate the behavior of power system stakeholders during a disaster. We validate our model using datasets of hurricane Harvey of Category 4 that hit Texas in August 2017 and hurricane Irma of Category 5 that made landfall in Florida in September 2017. We retrieve these datasets from Twitter and GoogleTrend and then apply natural language processing and language psychology analysis tools to deduce the social behavior of the end-users.

Psychiatric advance directives (PADs) are legal documents allowing competent individuals to declare their treatment preferences in advance of a mental health crisis. The objective of this thesis is to examine psychosocial perceptions of legal and mental health professionals in Ontario and Quebec regarding their knowledge and willingness to implement PADs. Two hundred professionals---psychiatrists, psychologists, lawyers and administrative tribunal members---participated in an Web-survey measuring psychosocial perceptions of clinical, ethical, legal and implementation factors of PADs. Results indicate Quebec professionals are more willing to begin using PADs than Ontario professionals. Mental health professionals reported more concern than legal professionals for medical malpractice lawsuits for overriding PADs. Advantages of PADs most commonly reported are patients' ability to declare their clear wishes ahead of time, respect for autonomous choice, and establishing a collaborative treatment plan with physicians. Disadvantages included patients' lack of awareness, treatment refusal, and being self-bound to an earlier decision.