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A practical result of the research conducted through completion of thesis was the interRAI Community Paramedicine Home Visit Assessment instrument. / This thesis presents a systematic framework for developing and evaluating a multi-dimensional patient assessment system for community paramedicine home visit programs. Underlying all of this work was a hypothesis that multi-dimensional patient assessment systems hold clinical utility to inform care planning activities, which in turn can direct appropriate patient care. I outline considerations for using assessment instruments to assist in the assessment process including strengths and weaknesses of using single-dimension or multi-dimensional assessment instruments when attempting to complete a consistently organized, multi-domain, and comprehensive assessment. The thesis includes a framework that outlines the major stages in developing and evaluating a new multi-dimensional patient assessment system. The framework uses community paramedicine home visit programs as an example of its application and subsequent chapters present and discuss key research questions related to each stage of the development and evaluation process; establishing a comprehensive set of clinical observations to be assessed and the related application of assessment findings to care planning activities. Two chapters explore existing assessment practices in community paramedicine home visit programs with findings that informed creation of a prototype assessment system that was pilot-tested. The fifth chapter describes results of the pilot-test and the sixth chapter investigates the clinical utility of the prototype assessment system to care planning of community paramedics. The development approach is informed by next-generation assessment practices and my work evaluating community paramedicine home visit programs provides a basis for appraisal of evidence in an emerging practice setting that does not have broadly established clinical practice guidelines. The accumulation of the evidence established in my thesis has led to the creation of a multi-dimensional patient assessment system for community paramedicine home visit programs. My research methods and findings can assist clinicians, decision makers or other researchers where a multi-dimensional assessment system is being developed or implemented. / Thesis / Candidate in Philosophy

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The aim of the thesis was to develop and evaluate a Computerised Decision Support System (CDSS) for use in pre-hospital care.The thesis was guided by a theoretical framework for developing and evaluating a complex intervention. The four studies used different designs and methods. The first study was a systematic review of randomised controlled trials. The second and the last studies had experimental and quasi-experimental designs, where the CDSS was evaluated in a simulation setting and in a clinical setting. The third study included in the thesis had a qualitative case study design.The main findings from the studies in the thesis were that there is a weak evidence base for the use of CDSS in pre-hospital care. No studies have previously evaluated the effect of CDSS in pre-hospital care. Due to the context, pre-hospital care is dependent on protocol-based care to be able to deliver safe, high-quality care. The physical format of the current paper based guidelines and protocols are the main obstacle to their use. There is a request for guidelines and protocols in an electronic format among both clinicians and leaders of the ambulance organisations. The use of CDSS in the pre-hospital setting has a positive effect on compliance with pre-hospital guidelines. The largest effect is in the primary survey and in the anamnesis of the patient. The CDSS also increases the amount of information collected in the basic pre-hospital assessment process. The evaluated CDSS had a limited effect on on-the-scene time.The developed and evaluated CDSS has the ability to increase pre-hospital patient safety by reducing the risks of cognitive bias. Standardising the assessment process, enabling explicit decision support in the form of checklists, assessment rules, differential diagnosis lists and rule out worst-case scenario strategies, reduces the risk of premature closure in the assessment of the pre-hospital patient. / För avläggande av doktorsexamen i Kvalitetsförbättring och ledarskap inom hälsa och välfärd som med tillstånd av Nämnden för utbildning och forskarutbildning vid Högskolan i Jönköping framläggs till offentlig granskning torsdagen den 5 juni 2014 kl.13.00 i sal M 204, Högskolan i Borås.

Patienter utsätts för onödiga transporter och efterföljande väntetid på akutmottagningen, vilket i sin tur leder till ett onödigt vårdlidande. Det är inte längre en självklar åtgärd för ambulanssjukvården att transportera alla patienter till akutmottagningen för fortsatt vård. Detta innebär att kravet har ökat på ambulanssjukvården och den prehospitala bedömningen. Mot bakgrund av dessa förutsättningar som idag gäller för ambulanssjukvård, är frågan om forskningen kan vägleda till hur den prehospitala bedömningen ska kunna underlättas.Syftet med studien är att beskriva prehospital bedömning i ambulanssjukvård och genom en forskningsöversikt har kvalitativ och kvantitativ forskning analyserats.I resultatet framkommer det att prehospital bedömning består av två huvudinnehåll, dels en vårdvetenskaplig där den prehospitala bedömningen ses som en kontinuerlig process och dels en medicinsk där den prehospitala bedömningen inriktas på att utifrån fastställda kriterier ringa in patientens vårdbehov. I den vårdvetenskapliga forskningen framkommer att vårdrelationen är en central del i den prehospitala bedömningen liksom att vinna patientens förtroende. I den medicinska forskningen framkommer att prehospital bedömning och triagering med hjälp av protokoll kan vara ett sätt att minska patientens vårdlidande. Protokoll kan ge en vägledning till alternativa vårdnivåer men måste kombineras med ett vårdvetenskapligt patientperspektiv och ett öppet förhållningssätt för att möta patienters individuella nyanser. Genom att möjliggöra patientstyrning till alternativa vårdnivåer, kan akutmottagningar avlastas och leda till att fler patienter kan vårdas hemma, dock i ringa omfattning. / <p>Program: Fristående kurs</p><p>Uppsatsnivå: C</p>

The aim of the thesis was to develop and evaluate a Computerised Decision Support System (CDSS) for use in pre-hospital care. The thesis was guided by a theoretical framework for developing and evaluating a complex intervention. The four studies used different designs and methods. The first study was a systematic review of randomised controlled trials. The second and the last studies had experimental and quasi-experimental designs, where the CDSS was evaluated in a simulation setting and in a clinical setting. The third study included in the thesis had a qualitative case study design. The main findings from the studies in the thesis were that there is a weak evidence base for the use of CDSS in pre-hospital care. No studies have previously evaluated the effect of CDSS in pre-hospital care. Due to the context, pre-hospital care is dependent on protocol-based care to be able to deliver safe, high-quality care. The physical format of the current paper based guidelines and protocols are the main obstacle to their use. There is a request for guidelines and protocols in an electronic format among both clinicians and leaders of the ambulance organisations. The use of CDSS in the pre-hospital setting has a positive effect on compliance with pre-hospital guidelines. The largest effect is in the primary survey and in the anamnesis of the patient. The CDSS also increases the amount of information collected in the basic pre-hospital assessment process. The evaluated CDSS had a limited effect on on-the-scene time. The developed and evaluated CDSS has the ability to increase pre-hospital patient safety by reducing the risks of cognitive bias. Standardising the assessment process, enabling explicit decision support in the form of checklists, assessment rules, differential diagnosis lists and rule out worst-case scenario strategies, reduces the risk of premature closure in the assessment of the pre-hospital patient.