Background: Pediatric chronic pain is prevalent and comes with diagnostic uncertainty and biopsychosocial complexity. The literature significantly lacks evidence and clinical guidance to inform triage decisions to interdisciplinary pediatric chronic pain programs, which likely impacts timely and appropriate access to much needed interdisciplinary care. Purpose: To methodically conduct foundational investigation into triage within interdisciplinary pediatric chronic pain programs to develop a preliminary series of Clinical Decision Support (CDS) triage tools grounded in evidence to facilitate nurses' triage decision-making. Methods: A pragmatic, multi-method study was conducted and fundamentally guided by the Knowledge to Action Framework (KTA). Included studies involved: 1) A modified Delphi study to attain expert consensus on the diagnostic expectations of pediatric patients referred to interdisciplinary chronic pain programs; 2) A systematic review of multidimensional biopsychosocial tools used in the pediatric chronic pain population, guided by the Multidimensional Biobehavioral Model of Pediatric Pain; and 3) An explorative descriptive qualitative study guided by the Cognitive Continuum Theory (CCT) and the Theoretical Domains Framework (TDF) to explore and describe the decision-making practices of and contextual influences on nurses triaging patients to interdisciplinary pediatric chronic pain programs. Findings: Following two survey rounds, the Delphi study demonstrated consensus on 84% of diagnostic items and general agreement regarding the diagnostic expectations of referred patients. The systematic review revealed six valid and reliable multidimensional biopsychosocial tools and highlighted 84 significant relationships between pain and functional interference across 11 biopsychosocial variables. The qualitative study emphasized the leading and complex triage role nurses lead in interdisciplinary pediatric chronic pain programs, and comprehensively described the triage process and determinants of the triage decision. Conclusions: Findings from the three studies have been integrated into the preliminary development of a series of CDS triage tools to be used in interdisciplinary pediatric chronic pain programs. This series offers decision guidance to accept or redirect care based on diagnostic clarity and a strategy to prioritize access to interdisciplinary care based on biopsychosocial needs. To determine clinical utility and validity of the tool, future research will target end-users to finalize tool development.

Motor vehicle crashes (MVCs) are a global public health concern. In 2020 alone, there were an estimated 6.76 million police reported crashes in the United States [1]. In the wake of an MVC, those involved may have been inflicted with serious or fatal injuries. Despite large research and development efforts to design vehicles and safety features to help reduce the frequency and severity of MVCs, crashes are, and will continue to be, a reality. In response to MVCs, first responders are tasked to provide crash victims with rapid immediate care and transport them to an appropriate facility. In spite of continued progress in emergency medicine, there are still many operational hurdles that emergency medical technicians need to overcome to perform their duties proficiently. Development and deployment of advanced automatic crash notification (AACN) systems have the potential to reduce the time between a crash and 911 system activation, especially for unseen roadway departures or crashes that render occupants incapacitated. Ultimately, AACN systems may aid first responders and improve MVC patient outcomes, however, these systems only target the earliest elements of an emergency response event. Therefore, the work contained in this dissertation aimed to identify additional areas for improvement within an emergency response event, specifically MVCs, and propose and/or develop solutions to address them. The first area pertained to emergency medical services (EMS) transportation, which can include responding to and transporting patients from an MVC. Through the analysis of the national EMS Information System database, an existing light vehicle naturalistic driving study, and a pilot ambulance-based naturalistic driving study, this dissertation provides a comprehensive investigation into EMS roadway interactions. The findings of these investigations confirmed that traffic interactions are a common issue and leading cause of EMS delay during response and transport phases. Even when ambulance operators drive with observed "due regard" and utilize emergency lights and sirens appropriate, many drivers were observed to yield the right of way inappropriately or in a delayed manner that resulted in safety critical events on open roadways and in intersections. The second area of improvement pertained to providing EMS with detailed patient information following an MVC. This took shape through the development of a post-crash injury triage system that provides first responders with occupant condition prior to on-scene arrival. The proposed system collects and shares crash occupant respiration rate, heart rate, and mental status through vehicle cabin integrated sensors and a post-crash response operator. This information, and additional vehicle specific crash details, are then populated into post-crash web application that responding agencies can view and interact with to strategically allocate response resources and predevelop transportation plans. Collectively, the work included in this dissertation identified challenges that EMS face when responding to MVCs, and produced findings that can be used to develop technology, update policies, and innovate in the transportation sector to improve emergency response and post-crash care. The identified safety and efficiency benefits not only apply to emergency respondents but encompass benefits to crash victims and all other road users. Although targeted at MVCs, the findings of this dissertation may also be applicable to many different types of emergencies and can benefit other public safety domains such as law enforcement, fire services, towing, and infrastructure maintenance. / Doctor of Philosophy / Motor vehicle crashes (MVCs) are a global public health concern. In 2020 alone, there were an estimated 6.76 million police reported crashes in the United States [1]. In the wake of an MVC, those involved may have been seriously or fatally injuries. Despite large research and development efforts to design vehicles and safety features to help reduce the frequency and severity of MVCs, crashes are, and will continue to be, a reality. In response to MVCs, first responders are tasked to provide crash victims with rapid immediate care and transport them to an appropriate facility. In spite of continued progress in emergency medicine, there are still many operational hurdles that emergency medical technicians need to overcome to perform their duties proficiently. Development and deployment of advanced automatic crash notification (AACN) systems have the potential to reduce the time between a crash when a 911 response is started, especially for unseen roadway departures or crashes that render occupants incapacitated. Ultimately, AACN systems may aid first responders and improve MVC patient outcomes, however, these systems only target the earliest elements of an emergency response event. Therefore, the work contained in this dissertation aimed to identify additional areas for improvement within an emergency response event, specifically MVCs, and propose and/or develop solutions to address them. The first area pertained to emergency medical services (EMS) transportation, which can include responding to and transporting patients from an MVC. Through the analysis of a national database, an existing light vehicle driving study, and a pilot ambulance-based driving study, this dissertation provides a comprehensive investigation into EMS roadway interactions. The findings can be used to better understand EMS roadway interactions and applied to develop innovative ways to improve safety and efficiency for all road users. The second area of improvement pertained to providing EMS with detailed patient information following an MVC. This took shape through the development of a post-crash injury triage system that provides first responders with occupant condition prior to on-scene arrival. The proposed system collects and shares crash occupant respiration rate, heart rate, and mental status, allowing responding agencies to strategically allocate response resources and predevelop transportation plans. Collectively, the work included in this dissertation identified challenges that EMS face when responding to MVCs, and produced findings that can be used to develop technology, update policies, and innovate in the transportation sector to improve emergency response and post-crash care. The identified safety and efficiency benefits not only apply to emergency respondents but encompass benefits to crash victims and all other road users. Although targeted at MVCs, the findings of this dissertation may also be applicable to many different types of emergencies and can benefit other public safety domains such as law enforcement, fire services, towing, and infrastructure maintenance. Therefore, the work contained in this dissertation aimed to identify additional areas for improvement within an emergency response event, specifically MVCs, and propose and/or develop solutions to address them. The first area pertained to emergency medical services (EMS) transportation, which can include responding to and transporting patients from an MVC. Through the analysis of a national database, an existing light vehicle naturalistic driving study, and a pilot ambulance-based naturalistic driving study, this dissertation provides a comprehensive investigation into EMS roadway interactions. The findings can be used to better understand EMS roadway interactions and applied to develop innovative ways to improve safety and efficiency for all road users. The second area of improvement pertained to providing EMS with detailed patient information following an MVC. This took shape through the development of a post-crash injury triage system that provides first responders with occupant condition prior to on-scene arrival. The proposed system collects and shares crash occupant respiration rate, heart rate, and mental status, allowing responding agencies to strategically allocate response resources and predevelop transportation plans. Collectively, the work included in this dissertation identified challenges that EMS face when responding to MVCs, and produced findings that can be used to develop technology, update policies, and innovate in the transportation sector to improve emergency response and post-crash care. The identified safety and efficiency benefits not only apply to emergency respondents but encompass benefits to crash victims and all other road users. Although targeted at MVCs, the findings of this dissertation may also be applicable to many different types of emergencies and can benefit other public safety domains such as law enforcement, fire services, towing, and infrastructure maintenance.

Bug-fixing, or fixing known errors in computer software, makes up a large portion of software development expenses. Once a bug is discovered, it must be assigned to an appropriate developer who has the necessary expertise to fix the bug. This bug-assignment task has traditionally been done manually. However, this manual task is time-consuming, error-prone, and tedious. Therefore, automatic bug assignment techniques have been developed to facilitate this task. Most of the existing techniques are report-based. That is, they work on bugs that are textually described in bug reports. However, only a subset of bugs that are observed as a faulty program execution are also described textually. Certain bugs, such as security vulnerability bugs, are only represented with a faulty program execution, and are not described textually. In other words, these bugs are represented by a code coverage, which indicates which lines of source code have been executed in the faulty program execution. Promptly fixing these software security vulnerability bugs is necessary in order to manage security threats. Accordingly, execution-based bug assignment techniques, which model a bug with a faulty program execution, are an important tool in fixing software security bugs. In this thesis, we compare WhoseFault, an existing execution-based bug assignment technique, to report-based techniques. Additionally, we propose DR_BEV (Developer Recommendation Based on Executed Vocabulary), a novel execution-based technique that models developer expertise based on the vocabulary of each developer's source code contributions, and we demonstrate that this technique out-performs the current state-of-the-art execution-based technique. Our observations indicate that report-based techniques perform better than execution-based techniques, but not by a wide margin. Therefore, while a report-based technique should be used if a report exists for a bug, our results should provide confidence in the scenarios in which only execution-based techniques are applicable. / Master of Science / Bug-fixing, or fixing known errors in computer software, makes up a large portion of software development expenses. Once a bug is discovered, it must be assigned to an appropriate developer who has the necessary expertise to fix the bug. This bug-assignment task has traditionally been done manually. However, this manual task is time-consuming, error-prone, and tedious. Therefore, automatic bug assignment techniques have been developed to facilitate this task. Most of the existing techniques are report-based. That is, they work on bugs that are textually described in bug reports. However, only a subset of bugs that are observed as a faulty program execution are also described textually. Certain bugs, such as security vulnerability bugs, are only represented with a faulty program execution, and are not described textually. In other words, these bugs are represented by a code coverage, which indicates which lines of source code have been executed in the faulty program execution. Promptly fixing these software security vulnerability bugs is necessary in order to manage security threats. Accordingly, execution-based bug assignment techniques, which model a bug with a faulty program execution, are an important tool in fixing software security bugs. In this thesis, we compare WhoseFault, an existing execution-based bug assignment technique, to report-based techniques. Additionally, we propose DR_BEV (Developer Recommendation Based on Executed Vocabulary), a novel execution-based technique that models developer expertise based on the vocabulary of each developer's source code contributions, and we demonstrate that this technique out-performs the current state-of-the-art execution-based technique.

No / To determine the accuracy of radiographers red dot or triage of accident and emergency (A&E) radiographs in clinical practice. MATERIALS AND METHODS Eligible studies assessed radiographers red dot or triage of A&E radiographs in clinical practice compared with a reference standard and provided accuracy data to construct 2×2 tables. Data were extracted on study eligibility and characteristics, quality, and accuracy. Pooled sensitivities and specificities and chi-square tests of heterogeneity were calculated. RESULT Three red dot and five triage studies were eligible for inclusion. Radiographers' red dot of A&E radiographs in clinical practice compared with a reference standard is 0.87 [95% confidence interval (CI) 0.85¿0.89] and 0.92 (0.91¿0.93) sensitivity and specificity, respectively. Radiographers' triage of A&E radiographs of the skeleton is 0.90 (0.89¿0.92) and 0.94 (0.93¿0.94) sensitivity and specificity, respectively; and for chest and abdomen is 0.78 (0.74¿0.82) and 0.91 (0.88¿0.93). Radiographers' red dot of skeletal A&E radiographs without training is 0.71 (0.62¿0.79) and 0.96 (0.93¿0.97) sensitivity and specificity, respectively; and with training is 0.81 (0.72¿0.87) and 0.95 (0.93¿0.97). Pooled sensitivity and specificity for radiographers without training for the triage of skeletal A&E radiographs is 0.89 (0.88¿0.91) and 0.93 (0.92¿0.94); and with training is 0.91 (0.88¿0.94) and 0.95 (0.93¿0.96). CONCLUSION Radiographers red dot or triage of A&E radiographs in clinical practice is affected by body area, but not by training.

L'accès aux services de santé et les longs délais d'attente sont l’un des principaux problèmes dans la plupart des pays du monde, dont le Canada et les États-Unis. Les organismes de soins de santé ne peuvent pas augmenter leurs ressources limitées, ni traiter tous les patients simultanément. C'est pourquoi une attention particulière doit être portée à la priorisation d'accès des patients aux services, afin d’optimiser l’utilisation de ces ressources limitées et d’assurer la sécurité des patients. En fait, la priorisation des patients est une pratique essentielle, mais oubliée dans les systèmes de soins de santé à l'échelle internationale. Les principales problématiques que l’on retrouve dans la priorisation des patients sont: la prise en considération de plusieurs critères conflictuels, les données incomplètes et imprécises, les risques associés qui peuvent menacer la vie des patients durant leur mise sur les listes d'attente, les incertitudes présentes dans les décisions des cliniciens et patients, impliquant l'opinion des groupes de décideurs, et le comportement dynamique du système. La priorisation inappropriée des patients en attente de traitement a une incidence directe sur l’inefficacité des prestations de soins de santé, la qualité des soins, et surtout sur la sécurité des patients et leur satisfaction. Inspirés par ces faits, dans cette thèse, nous proposons de nouveaux cadres hybrides pour prioriser les patients en abordant un certain nombre de principales lacunes aux méthodes proposées et utilisées dans la littérature et dans la pratique. Plus précisément, nous considérons tout d'abord la prise de décision collective incluant les multiples critères de priorité, le degré d'importance de chacun de ces critères et de leurs interdépendances dans la procédure d'établissement des priorités pour la priorisation des patients. Puis, nous travaillons sur l'implication des risques associés et des incertitudes présentes dans la procédure de priorisation, dans le but d'améliorer la sécurité des patients. Enfin, nous présentons un cadre global en se concentrant sur tous les aspects mentionnés précédemment, ainsi que l'implication des patients dans la priorisation, et la considération des aspects dynamiques du système dans la priorisation. À travers l'application du cadre global proposé dans le service de chirurgie orthopédique à l'hôpital universitaire de Shohada, et dans un programme clinique de communication augmentative et alternative appelé PACEC à l'Institut de réadaptation en déficience physique de Québec (IRDPQ), nous montrons l'efficacité de nos approches en les comparant avec celles actuellement utilisées. Les résultats prouvent que ce cadre peut être adopté facilement et efficacement dans différents organismes de santé. Notamment, les cliniciens qui ont participé à l'étude ont conclu que le cadre produit une priorisation précise et fiable qui est plus efficace que la méthode de priorisation actuellement utilisée. En résumé, les résultats de cette thèse pourraient être bénéfiques pour les professionnels de la santé afin de les aider à: i) évaluer la priorité des patients plus facilement et précisément, ii) déterminer les politiques et les lignes directrices pour la priorisation et planification des patients, iii) gérer les listes d'attente plus adéquatement, vi) diminuer le temps nécessaire pour la priorisation des patients, v) accroître l'équité et la justice entre les patients, vi) diminuer les risques associés à l’attente sur les listes pour les patients, vii) envisager l'opinion de groupe de décideurs dans la procédure de priorisation pour éviter les biais possibles dans la prise de décision, viii) impliquer les patients et leurs familles dans la procédure de priorisation, ix) gérer les incertitudes présentes dans la procédure de prise de décision, et finalement x) améliorer la qualité des soins. / Access to health care services and long waiting times are one of the main issues in most of the countries including Canada and the United States. Health care organizations cannot increase their limited resources nor treat all patients simultaneously. Then, patients’ access to these services should be prioritized in a way that best uses the scarce resources, and to ensure patients’ safety. In fact, patients’ prioritization is an essential but forgotten practice in health care systems internationally. Some challenging aspects in patients’ prioritization problem are: considering multiple conflicting criteria, incomplete and imprecise data, associated risks that threaten patients on waiting lists, uncertainties in clinicians’ decisions, involving a group of decision makers’ opinions, and health system’s dynamic behavior. Inappropriate prioritization of patients waiting for treatment, affects directly on inefficiencies in health care delivery, quality of care, and most importantly on patients’ safety and their satisfaction. Inspired by these facts, in this thesis, we propose novel hybrid frameworks to prioritize patients by addressing a number of main shortcomings of current prioritization methods in the literature and in practice. Specifically, we first consider group decision-making, multiple prioritization criteria, these criteria’s importance weights and their interdependencies in the patients’ prioritization procedure. Then, we work on involving associated risks that threaten patients on waiting lists and handling existing uncertainties in the prioritization procedure with the aim of improving patients’ safety. Finally, we introduce a comprehensive framework focusing on all previously mentioned aspects plus involving patients in the prioritization, and considering dynamic aspects of the system in the patients’ prioritization. Through the application of the proposed comprehensive framework in the orthopedic surgery ward at Shohada University Hospital, and in an augmentative and alternative communication (AAC) clinical program called PACEC at the Institute for Disability Rehabilitation in Physics of Québec (IRDPQ), we show the effectiveness of our approaches comparing the currently used ones. The implementation results prove that this framework could be adopted easily and effectively in different health care organizations. Notably, clinicians that participated in the study concluded that the framework produces a precise and reliable prioritization that is more effective than the currently in use prioritization methods. In brief, the results of this thesis could be beneficial for health care professionals to: i) evaluate patients’ priority more accurately and easily, ii) determine policies and guidelines for patients’ prioritization and scheduling, iii) manage waiting lists properly, vi) decrease the time required for patients’ prioritization, v) increase equity and justice among patients, vi) diminish risks that could threaten patients during waiting time, vii) consider all of the decision makers’ opinions in the prioritization procedure to prevent possible biases in the decision-making procedure, viii) involve patients and their families in the prioritization procedure, ix) handle available uncertainties in the decision-making procedure, and x) increase quality of care.

Considerando-se que uma das tarefas mais comuns para um perito judicial que atua na área da informática é procurar vestígios de interesse no conteúdo de dispositivos de armazenamento de dados (DADs), que esses vestígios na maioria das vezes consistem em palavras-chave (PChs) e durante o tempo necessário para realização da duplicação do DAD o perito fica praticamente impossibilitado de interagir com os dados contidos no mesmo, decidiu-se verificar a hipótese de que seja possível na etapa de coleta, realizar simultaneamente à duplicação do DAD a varredura para procurar PCHs em dados brutos (raw data), sem com isso impactar significativamente o tempo de duplicação. O principal objetivo desta tese é propor um método que possibilite identificar os DADs com maior chance de conter vestígios de interesse para uma determinada perícia ao término da etapa de coleta, baseado na quantidade de ocorrências de PCHs encontradas por um mecanismo de varredura que atua no nível de dados brutos. A partir desses resultados é realizada uma triagem dos DADs. Com os resultados da triagem é realizado um processo de ranqueamento, indicando quais DADs deverão ser examinados prioritariamente na etapa de análise. Os resultados dos experimentos mostraram que é possível e viável a aplicação do método sem onerar o tempo de duplicação e com um bom nível de precisão. Em muitos de casos, a aplicação do método contribui para a diminuição da quantidade de DADs que devem ser analisados, auxiliando a diminuir o esforço humano necessário. / Considering that one of the most common tasks for a legal expert acting in the information technology area is to look for invidences of interest in the content data storage devices (DADs). In most cases these evidences consist of keywords. During the time necessary to perform the DAD duplication, the expert is practically unable to interact with the data contained on DAD. In this work we have decided to verify the following hypothesis: It is possible, at the collection stage, to simultaneously hold the duplication of the DAD and scan to search for keywords in raw data, without thereby significantly impact the duplication time. The main objective of this thesis is to propose a method that allows to identify DADs with a strong chance of containing evidences of interest for a particular skill at the end of the collection stage, based on the keywords occurrences found by a scanner mechanism that operates at the raw data level. Based on these results, a triage of DADs is established. With the results of the triage, a ranking process is made, providing an indication of which DADs should be examined first at the analysis stage. The results of the ours experiments showed that it is possible and feasible to apply the method without hindering the duplication time and with a certain level of accuracy. In most cases, the application of the method contributes to reduce the number of DADs that must be analyzed, helping to reduces the human effort required.

No description available.

Considerando-se que uma das tarefas mais comuns para um perito judicial que atua na área da informática é procurar vestígios de interesse no conteúdo de dispositivos de armazenamento de dados (DADs), que esses vestígios na maioria das vezes consistem em palavras-chave (PChs) e durante o tempo necessário para realização da duplicação do DAD o perito fica praticamente impossibilitado de interagir com os dados contidos no mesmo, decidiu-se verificar a hipótese de que seja possível na etapa de coleta, realizar simultaneamente à duplicação do DAD a varredura para procurar PCHs em dados brutos (raw data), sem com isso impactar significativamente o tempo de duplicação. O principal objetivo desta tese é propor um método que possibilite identificar os DADs com maior chance de conter vestígios de interesse para uma determinada perícia ao término da etapa de coleta, baseado na quantidade de ocorrências de PCHs encontradas por um mecanismo de varredura que atua no nível de dados brutos. A partir desses resultados é realizada uma triagem dos DADs. Com os resultados da triagem é realizado um processo de ranqueamento, indicando quais DADs deverão ser examinados prioritariamente na etapa de análise. Os resultados dos experimentos mostraram que é possível e viável a aplicação do método sem onerar o tempo de duplicação e com um bom nível de precisão. Em muitos de casos, a aplicação do método contribui para a diminuição da quantidade de DADs que devem ser analisados, auxiliando a diminuir o esforço humano necessário. / Considering that one of the most common tasks for a legal expert acting in the information technology area is to look for invidences of interest in the content data storage devices (DADs). In most cases these evidences consist of keywords. During the time necessary to perform the DAD duplication, the expert is practically unable to interact with the data contained on DAD. In this work we have decided to verify the following hypothesis: It is possible, at the collection stage, to simultaneously hold the duplication of the DAD and scan to search for keywords in raw data, without thereby significantly impact the duplication time. The main objective of this thesis is to propose a method that allows to identify DADs with a strong chance of containing evidences of interest for a particular skill at the end of the collection stage, based on the keywords occurrences found by a scanner mechanism that operates at the raw data level. Based on these results, a triage of DADs is established. With the results of the triage, a ranking process is made, providing an indication of which DADs should be examined first at the analysis stage. The results of the ours experiments showed that it is possible and feasible to apply the method without hindering the duplication time and with a certain level of accuracy. In most cases, the application of the method contributes to reduce the number of DADs that must be analyzed, helping to reduces the human effort required.

Bakgrund: Telefonsjuksköterskors arbetsuppgifter är att råda, stötta och göra bedömningar i en komplex situation. Studier har gjorts på telefonsjuksköterskors erfarenhet i telefonrådgivning men få har inkluderat observation. Syfte: Denna studie syftar till att beskriva hur telefonsjuksköterskor använder webbaserat beslutsstöd i telefonrådgivning på vårdcentral och deras erfarenheter av detta. Metod: Studien är kvalitativ med beskrivande design. Observationer och halvstrukturerade intervjuer utfördes på vårdcentral. Sex distriktssköterskor som hade arbetat minst ett år i telefonrådgivning deltog. Analys: Data från observationerna och intervjuerna bearbetades med kvalitativ innehållsanalys. Resultat: Telefonsjuksköterskorna använde dataprogrammet Rådgivningsstödet Webb (RGS Webb) som en stödjande funktion vilket skapade trygghet. För stora textmassor med långa sökvägar försvårade arbetet. Faktorer som organisatorisk tidspress, avsaknad av hjälpmedel för kommunikation med patienter som talar annat språk och lång erfarenhet minskade användandet av RGS Webb.  Diskussion: Telefonsjuksköterskorna upplevde stöd i att RGS Webb gav mycket och korrekt information som kunde ges till vårdtagare. Detta ledde till säkrare bedömningar som ökade patientsäkerheten. RGS Webb upplevdes svårarbetat med mycket textmassor. Utbildning behövs inom informationsteknik eftersom sjuksköterskorna idag förväntas vara stora användare av IT. Slutsats: RGS Webb stödjer, påminner, skapar trygghet och ger ny kunskap. Svårigheter som fanns utgjorde hinder i användandet och RGS Webb användes i mindre utsträckning eller inte alls. / Background: The telephone nurse's duties are to advise, support and make assessments in a complex situation. Studies have been conducted on the telephone nurse's experience in telephone counseling, but few have included observation. Aim: This study aims at describing how telephone nurses use computer decision support system in telephone counseling at the health center and their experiences with this. Method: The study is qualitative with descriptive design. Observations and semi-structured interviews were conducted at the health center. Six district nurses who had worked for at least one year in telephone consulting participated. Analysis: The data from the observations and interviews were processed using qualitative content analysis. Result: The telephone nurse used the computer decision support system (RGS Webb) as a supportive feature, which created security. Too large text pads with long paths made work difficult. Factors such as organizational time pressure, lack of tools for communication with patients who speak other languages and long experience reduced the use of RGS Webb. Discussion: The telephone nurse found support in the fact that RGS Webb provided very accurate information that could be given to caregivers. This leads to safer assessments that increase patient safety. RGS Webb was experienced hard-working with a lot of text masses. Education is needed in information technology because nurses today are expected to be major users of IT. Conclusion: RGS Webb supports, reminds, creates security and provides new knowledge. Difficulties that existed were barriers to use and RGS Webb was used to a lesser extent or not at all.

Successful triage is the basis for sound emergency department (ED) care, whereas unsuccessful triage could result in adverse outcomes. ED triage is a rather unexplored area in the Swedish health care system. This thesis contributes to our understanding of this complex nursing task. The main focus of this study has been on the organisation, performance, and decision making in Swedish ED triage. Specific aims were to describe the Swedish ED triage context, describe and compare registered nurses’ (RNs) allocation of acuity ratings, use of thinking strategies and the way they structure the ED triage process. In this descriptive, comparative, and correlative research project quantitative and qualitative data were collected using telephone interviews, patient scenarios and think aloud method. Both convenience and purposeful sampling were used when identifying the participating 69 nurse managers and 423 RNs from various types of hospital-based EDs throughout the country. The results showed national variation, both in the way triage was organised and in the way it was conducted. From an organisational perspective, the variation emerged in several areas: the use of various triageurs, designated triage nurses, and triage scales. Variation was also noted in the accuracy and concordance of allocated acuity ratings. Statistical methods provided limited explanations for these variations, suggesting that RNs’ clinical experience might have some affect on the RNs’ triage accuracy. The project identified several thinking strategies used by the RNs, indicating that the RNs, amongst other things, searched for additional information, generated hypotheses about the fictitious patients and provided explanations for the interventions chosen. The RNs formed relationships between their interventions and the fictitious patients’ symptoms. The RNs structured the triage process in several ways, beginning the process by searching for information, generating hypotheses, or allocating acuity ratings. Comparison of RNs’ use of thinking strategies and the structure of the triage process based on triage accuracy revealed only slight differences. The findings in this dissertation indicate that the way a patient is triaged, and by whom, depends upon the particular organisation of the ED. Moreover, the large variation in RNs triage accuracy and the inter-rater agreement and concordance of the allocated acuity ratings suggest that the acuity rating allocated to a patient may vary considerably, depending on who does the allocation. That neither clinical experience nor the RNs’ decision-making processes alone can explain the variations in the RNs triage accuracy indicates that accuracy might be influenced by individual and contextual factors. Future studies investigating triage accuracy are recommended to be carried out in natural settings. In conclusion, Swedish ED triage is permeated by diversity, both in its organisation and in its performance. The reasons for these variations are not well understood.