Introdução: O transporte médico de crianças gravemente enfermas envolve particularidades que aumentam o risco de complicações, que podem contribuir para o aumento no tempo de internação e mortalidade. Objetivos: Avaliar a frequência e os tipos de complicações observadas durante o transporte pré- hospitalar e inter-hospitalar de crianças gravemente enfermas, assim como o impacto dessas complicações na mortalidade, no tempo de internação hospitalar e nos custos hospitalares. Pacientes e Métodos: Estudo realizado em duas etapas: a primeira foi um estudo transversal, no qual, por meio de entrevista padronizada com o médico que admitiu as crianças gravemente enfermas que necessitaram de transporte pré-hospitalar ou inter-hospitalar, foram identificadas e caracterizadas possíveis complicações ocorridas durante esse transporte. Estes dados foram auditados por três médicos independentes que definiram a presença ou ausência de complicações durante o transporte. A segunda etapa constituiu-se de uma coorte prospectiva, na qual os pacientes, divididos em dois grupos distintos (com e sem complicações durante o transporte), foram seguidos, prospectivamente, por 60 dias, observando-se a ocorrência de morte ou alta hospitalar. Resultados: Foram incluídas 143 crianças no estudo. Pelo menos uma complicação durante o transporte foi observada em 74 pacientes (52%). As complicações mais frequentes foram relacionadas com as vias aéreas (69%), seguidas por distúrbios metabólicos (47%), alterações cardiovasculares (40%) e falhas relacionadas aos dispositivos e à monitorização (37%). Na análise univariada, os seguintes preditores para ocorrência de complicações durante o transporte foram observados: peso <10Kg (risco relativo - RR: 1,52; intervalo de confiança (IC 95%: 1,11-2,09); distância >100Km (RR: 1,67; IC 95%: 1,16-2,40); presença de doença respiratória (RR: 1,46; IC 95%: 1,06-1,95) e comorbidades (RR: 1,68; IC 95%: 1,23-2,30). Já na análise multivariada, não foram observados preditores independentes para ocorrência de complicações. A ocorrência de complicações durante o transporte foi associada com maior taxa de mortalidade hospitalar (hazard ratio - HR: 5,668; IC 95%: 1,26-26,65; p=0,0130) e menor taxa de alta hospitalar (HR: 0,48; IC 95%: 0,31-0,74; p=0,0007). Após a aplicação da regressão de Cox para ajuste de potenciais fatores de confusão, a presença de complicação durante o transporte permaneceu associada com o índice de mortalidade hospitalar (HR: 6,74; IC 95%: 1,40-32,34; p=0,017), contudo deixou de ser associada com o tempo para a alta hospitalar (HR: 0,76; IC 95%: 0,49- 1,16; p=0,213). Conclusões: As complicações foram frequentes durante o transporte pediátrico. A presença de doenças respiratórias, peso <10Kg, presença de comorbidades e a distância >100 Km foram preditores de risco para a ocorrência dessas complicações. As complicações ocorridas durante o transporte foram associadas com o aumento nas taxas de mortalidade hospitalar. / Introduction: The medical transport of critically ill children involves characteristics that increase the risk of complications, which can contribute to an increase in length of stay and mortality. Objectives: To evaluate the frequency and type of complications observed during the pre-hospital and inter-hospital transport of critically ill children, as well as the impact of these complications on mortality, length of hospital stay and hospital costs. Patients and Methods: A study carried out in two stages: the first was a cross-sectional study where through a standardized interview with the doctor who admitted the critically ill children requiring pre-hospital or inter-hospital transport identified and characterized possible complications during this transport. These data were audited by three independent doctors who defined the presence or absence of complications during transport. The second stage consists of a prospective cohort study, where patients divided into two groups (with and without complications during transportation) were followed prospectively for 60 days observing the occurrence of death or hospital discharge. Results: We included 143 children in the study. At least one complication during transportation was observed in 74 patients (52%). The most frequent complications have been associated with airway (69%), followed by metabolic disorders (47%), cardiovascular disorders (40%) and failure in the device and monitoring (37%). In the uni-variate analysis, the following predictors for the occurrence of complications during transport were observed: weight <10 kg (relative risk - RR: 1.52; 95% confidence interval - CI: 1.11-2.09); distance greater than 100 km (RR: 1.67; 95% CI: 1.16-2.40); presence of respiratory disease (RR: 1.46; 95% CI: 1.06-1.95) and associated comorbidity (RR: 1.68; 95% CI: 1.23- 2.30). In the multivariate analysis, no independent predictors were observed for the occurrence of complications. The occurrence of complications during transport was associated with higher hospital mortality (hazard ratio - HR: 5.668; 95% CI: 1.26-26.65; p=0.0130) and a lower hospital discharge rate (HR: 0.48; 95% CI: 0.31-0.74; p=0.0007). After Cox regression to adjust for potential confounding factors, the presence of complications during transport remained associated with hospital mortality (HR: 6.74; IC 95%: 1.40-32.34; p=0.017), however, was not associated with hospital discharge rates (HR: 0.76; 95% CI: 0.49-1.16; p=0.213). Conclusions: The complications were common during pediatric transport. Distance greater than 100 km, presence of respiratory disease, associated comorbidity and weight <10 kg were risk predictors for occurrence of complications. Complications during pediatric transport were associated with increased hospital mortality rates.

Aim:  To describe and develop understanding of  the patient’s first encounter with the involved persons at the scene of an accident and at the emergency department; with a special focus on describing the meaning of emergency care of patients in these caring contexts.  Method: The thesis uses a reflective lifeworld research (RLR) approach founded on phenomenological philosophy. The purpose with this approach is to describe the essential meaning and the variations of a phenomenon. Interviews with a lifeworld perspective were used for data collection and analyzed according to the RLR approach for searching for the essence of the phenomenon.  The four essences in the studies (I-IV) establish a general structure for the phenomenon. Findings:  Emergency care is characterized by an organisation, whose goal and resources are focused on life-saving, and that encounters a human being with needs of emergency care as well as existential support. The responsibility in emergency care means an intertwining of doing and being.  The one who is in charge takes responsibility for performing or “doing” medical actions, and by “being” close and present in the situation the patient can at the same time feel an existential support. The responsibility for the injured or ill body is handed over to a chain of persons with more and more specialized competence and resources. This hand-over entails a relief for all involved but fails in one link in the chain, namely to explicitly hand back  the responsibility to the patient.  When the patient’s condition allows the distance to be larger the responsibility pales and the existential support decreases. A gap between doing and being arises where the patient is left to regain control and independence. The intertwining of doing and being, which appears as soon as the one in charge is close and present to the patient, facilitates the hand-over to the patient who in a natural way is able to receive the responsibility with possibilities to be able to conclude the encounter. Conclusions: A new understanding of emergency care appears which entails more than just life support measures.  Emergency care includes different ways of communication in order to hand over the responsibility and complete the care chain back to the patient in a safe way. The results highlight the importance of empowering patients with a confirming, communicative contact throughout the whole caring process in order for them to retain their identity. There are also implications for educating students and personnel in inter-professional communication and work. In order to assist the intertwining between doing and being there are needs for the development of supportive structures for inter-professional reflection, which in turn would improve the interaction between patients and professionals in their encounter.

Made available in DSpace on 2014-12-17T14:46:49Z (GMT). No. of bitstreams: 1 IsabelKFC_DISSERT.pdf: 2842147 bytes, checksum: 5940c197670eef58d4b127c85880497a (MD5) Previous issue date: 2011-12-02 / Exploratory, descriptive and quantitative study with prospective data, performed in the Mobile Emergency Care Service in the metropolitan region of Natal/RN, in order to identify the knowledge of the multidisciplinary team about the rules of standard precautions and worker safety, to identify occupational hazards peculiar to the activities of this service; characterize work-related accidents (WRA) and know the procedures adopted after each WRA. The population consisted of 162 professionals and data were collected between the months of November and December 2010. As for personal and professional characteristics, of the 162 professional, 12,96% were physicians; 6,79%, nurses; 33,95%, nursing technicians, 46,29%, conductors; 74,70% were male; 43,21% were between 31 and 40 years old; 69,33% lived in Natal/RN, 50,00% had completed high school; 58,64% were married; 69,75% had children, 46,91% were between 1 and 4 years of training; 61,73% had improvement courses; 59,25% had 3 to 4 years of service; 54,32%, with 1-4 years experience in emergency; 44,44% received 1-2 minimum wages; 78,40% received insalubrity premium; 67,28% worked in Basic Support Unit (BSU); 83,95% had journey on SAMU Metropolitano of 31-40 hours per week; 52,47% had other employments. As for knowledge of rules of standard precautions, safety and occupational hazards, 99,38% knew what it was WRA; 62,96% gave incomplete answers; 74,07% knew the rules of prevent WRA; 46,67% acquired this knowledge in lectures; 53,09% knew Personal Protective Equipment (PPE); 71,60% gave incorrect answers about the importance of standard precautions; 45,06% never received an educational intervention on this issue; 89,51% said that educational interventions in the prevention of WRA are very important; 90,12% pointed out this as a very important issue in the workplace; 27,00% suggested guidance on the topic in the workplace; regarding the physical hazards, 34,57% considered noise as the most important; about chemical hazards, 78,40% chose the gases and smoke; for biological hazards, 48,77% reported contact with the blood; for mechanical hazards, 80,86% said that were transport accidents; about ergonomic risks, 40,12% say it is the tension/stress in the care of critically ill, psychiatric and aggressive patients; and there was an average of 4,5 to the feeling of safety in the workplace. Regarding the data on the WRAs occurred, 31,48% experienced at least one accident event; 72,55% did not notify it; 60,98% answered that there was no routine for notification; 56,86% were performing patient transportation; 49,02% were hurt in the Basic Support Unit/Rescue Unit (BSU/RH); 60,78% occurred during the day; 96,08% of professionals were in normal work schedule (24 hours on duty); 31,37% had contusion; 58.82% had damage to members/pelvic girdle; 43,14% had traffic accidents. About the evolution of the WRA, 62,75% did not have to take time away from work; 76,47% had no sequelae; 88,24% did not require rehabilitation; no professional had a change of occupation. And by means of univariate logistic regression, showed that the nurses and male sex were risk factors for the occurrence of WRA. We conclude that there were gaps in the knowledge of staff regarding WRA, emphasizing the need for continuing education in biosafety in the service. / Estudo explorat?rio, descritivo, quantitativo e dados prospectivos, realizado no Servi?o de Atendimento M?vel de Urg?ncia da Regi?o Metropolitana de Natal/RN, com vistas a identificar o conhecimento da equipe multiprofissional acerca das normas de precau??es padr?o e seguran?a do trabalhador; identificar os riscos ocupacionais peculiares ?s atividades desenvolvidas nesse servi?o; caracterizar os acidentes de trabalho (AT) e conhecer os procedimentos adotados ap?s cada AT. A popula??o constou de 162 profissionais e os dados foram coletados entre os meses de novembro e dezembro de 2010. Quanto ? caracteriza??o pessoal e profissional, dos 162 profissionais, 12,96% eram m?dicos; 6,79%, enfermeiros; 33,95%, t?cnicos de enfermagem; 46,29%, condutores; 74,70% do sexo masculino; 43,21% tinham entre 31 e 40 anos; 69,33% residiam em Natal/RN; 50,00% possu?am o ensino m?dio completo; 58,64% casados; 69,75% tinham filhos; 46,91% tinham entre 1 e 4 anos de forma??o; 61,73% possu?am cursos de atualiza??o; 59,25% estavam com 3 a 4 anos de servi?o; 54,32%, com 1 a 4 anos de experi?ncia na urg?ncia; 44,44% recebiam de 1 a 2 sal?rios; 78,40% recebiam insalubridade; 67,28% atuavam na USB; 83,95% tinham jornada no SAMU Metropolitano de 31 a 40 horas semanais; 52,47% possu?am outro v?nculo empregat?cio. Quanto ao conhecimento sobre normas de precau??es padr?o, seguran?a e riscos ocupacionais, 99,38% sabiam o que era AT; 62,96% deram respostas incompletas; 74,07% conheciam as normas de AT; 46,67% adquiriram esse conhecimento em palestras; 53,09% conheciam os EPIs; 71,60% deram respostas incorretas sobre a import?ncia das PPs; 45,06% nunca receberam interven??o educativa sobre essa tem?tica; 89,51% disseram serem muito importante as interven??es educativas na preven??o de ATs; 90,12%, apontaram como muito importante este tema no ambiente de trabalho; 27,00% sugeriram a orienta??o sobre o tema no pr?prio local de trabalho; dentre os riscos f?sicos, 34,57% consideraram os ru?dos como o mais importante; dos riscos qu?micos, 78,40% referiram os gases e fuma?a; dos riscos biol?gicos, 48,77% citaram o contato com o sangue; dos riscos mec?nicos, 80,86% disseram que eram os acidentes de transporte; dos riscos ergon?micos, 40,12% afirmaram ser a tens?o/estresse no atendimento aos pacientes graves, psiqui?tricos e agressivos; e houve uma m?dia de 4,5 para o sentimento de seguran?a no ambiente de trabalho. Em rela??o aos dados sobre os ATs ocorridos, 31,48% sofreram pelo menos um evento acident?rio; 72,55% n?o notificaram; 60,98% responderam que n?o existia rotina para notifica??o; 56,86% estavam realizando o transporte de pacientes; 49,02% se acidentaram na USB/UR; 60,78% aconteceram durante o dia; 96,08% dos profissionais estavam em escala de trabalho normal (plant?o 24hs); 31,37% sofreram contus?o; 58,82% les?es nos membros/cintura p?lvica; 43,14% foram acidentes de transporte. Quanto ? evolu??o do AT, 62,75% n?o precisaram de afastamento do trabalho; 76,47% n?o tiveram sequelas; 88,24% n?o precisaram de reabilita??o; nenhum profissional precisou mudar de ocupa??o. E, por meio da regress?o log?stica univariada, evidenciou-se que os enfermeiros e o sexo masculino eram fatores de risco para a ocorr?ncia de AT. Conclu?mos que havia lacunas no conhecimento da equipe no que concerne aos AT, enfatizando-se a necessidade da educa??o permanente em biosseguran?a no servi?o.

Made available in DSpace on 2014-12-17T14:46:58Z (GMT). No. of bitstreams: 1 GrayceLTC_DISSERT.pdf: 1835806 bytes, checksum: f4f84109098e5cafa4fd9ac77f73ad99 (MD5) Previous issue date: 2013-02-07 / The attention with safety of the patients is important in the quality of the nursing and health care. In the pre-hospital care, such care is essential on site with the purpose of avoiding possible consequences to the individual, ensuring a fast and appropriate care, with improvement of the morbidity and reduction of the mortality. This medical attention is equally associated with the significant risks of adverse events and serious mistakes, which can be reduced with the awareness of the professionals, organization and quality management. It is a descriptive, transversal research, of quantitative approach, with the objective of identifying the risks for the safety of the patient during the mobile pre-hospital care under the view of the nurses, in a city of the Brazilian Northeast. The sample was formed by 23 nurses. The inclusion criteria: to have at least two years of experience and accept to participate on the research. The data collection was done in two steps, first photo collection, through the adapted method of photographic analysis, and the second with the application of questionnaire, divide in two parts: socio-professional data and digital photo punctuation instrument of the patient s safety. The majority of the nurses had an average working time in the mobile pre-hospital care of six years and six months, in the age group of 38 to 53 years old (69,56%) and with Lato sensu specialization (73,91%), being (29,41%) emergency and (29,41%) in intensive care. The (74%) have the Advance Cardiac Life Support (ACLS) and (100%) have the Pre-Hospital Trauma Life Support (PHTLS); (91, 30%) know the thematic safety of the patient. On the pictures it was observed a bigger variability of the categories (risks) where 44% of variance emerged on the first picture of the research. The pictures 4 and 9 with the average below 5 were classified as very insecure, while pictures 7 and 3 with an average above 7, very secure. On the results of risks observed for the patient s safety in the mobile pre-hospital care five categories emerged: organization and packaging of the equipment and materials, routines and specificities in the mobile pre-hospital care, risks on the management of medications, for traumas and infections. Starting from the analysis of these risks, it was proposed ten steps for the safety in the mobile pre-hospital care: 1- Identify the patient; 2- Safety related to prevention of infection; 3- Safety in the management of medications; 4- Safety and standardization of the packaging of equipment and materials; 5- Attention to the specificities of the mobile pre-hospital care; 6- Incentive and value the participation of the patient and family; 7- Promote the communication with the central of regulation; 8- Prevention of traumas and falls; 9- Protect the skin from additional injuries; 10- Understand the benefit of all the equipment in the ambulance. The multiple risks and their emerged combinations on the research indicate a variety of actions to be developed and stimulated, like the use of steps for the patient s safety in the mobile pre-hospital care which contributes with the aid and management of risks, reduction of mistakes, disabilities and death / A aten??o com a seguran?a dos pacientes ? importante na qualidade da assist?ncia de enfermagem e dos cuidados de sa?de. No atendimento pr?-hospitalar, estes cuidados s?o essenciais no local do evento, com prop?sito de minimizar poss?veis consequ?ncias ao indiv?duo, garantindo um atendimento precoce e adequado, com melhoria da morbidade e diminui??o da mortalidade. Estes atendimentos igualmente associam-se a riscos significativos de eventos adversos e erros graves, que podem ser diminu?dos com a conscientiza??o dos profissionais, organiza??o e qualidade da gest?o. Trata-se de estudo descritivo, transversal, de abordagem quantitativa, com o objetivo de identificar os riscos para a seguran?a do paciente no atendimento pr?-hospitalar m?vel sob a ?tica dos enfermeiros, em uma cidade do Nordeste Brasileiro. A amostra da pesquisa foi formada por 23 enfermeiros. Os crit?rios de inclus?o foram: ter no m?nimo dois anos de experi?ncia e aceitarem participar da pesquisa. A coleta de dados foi realizada em duas etapas: primeiramente coleta de fotos atrav?s do m?todo adaptado de an?lise fotogr?fica, e a segunda com a aplica??o de question?rio, dividido em duas partes: dados s?cio-profissionais e instrumento de pontua??o de fotografia digital sobre a seguran?a do paciente. Encontrou-se a predomin?ncia de enfermeiros com tempo m?dio de trabalho no atendimento pr?-hospitalar m?vel de seis anos e seis meses, na faixa et?ria de 38 a 53 anos (69,56%) e com especializa??o Lato sensu (73,91%), sendo (29,41%) em urg?ncia e emerg?ncia e (29,41%) em terapia intensiva. Possuem o Advanced Cardicologic Life Support (ACLS) (74%) e o Pre Hospital Trauma Life Support (PHTLS) (100%); conhecem a tem?tica seguran?a do paciente (91,30%). Nas fotos observou-se uma maior variabilidade de categorias (riscos) onde 44% de vari?ncia emergiu na foto 01 do estudo. As fotografias 4 e 9, com m?dias abaixo de 5, foram classificadas como muito inseguras, enquanto que as fotos 7 e 3 com m?dias acima de 7, muito seguras. Dos resultados de riscos observados para a seguran?a do paciente no atendimento pr?-hospitalar m?vel emergiram cinco categorias: organiza??o e acondicionamento de equipamentos e materiais, rotinas e especificidades no atendimento pr?-hospitalar m?vel, riscos para a administra??o de medicamentos, para traumas e para infec??o. Partindo da an?lise desses riscos foram propostos dez passos para a seguran?a do paciente no atendimento pr?-hospitalar m?vel: 1- Identificar o paciente; 2- Seguran?a relacionada ? preven??o de infec??o; 3- Seguran?a na administra??o de medicamentos; 4- Seguran?a e padroniza??o do acondicionamento de equipamentos e materiais; 5- Aten??o para as especificidades do atendimento pr?-hospitalar m?vel; 6- Incentivar e valorizar a participa??o do paciente e fam?lia; 7- Promover a comunica??o com a central de regula??o; 8- Preven??o de traumas e quedas; 9- Proteger a pele de les?es adicionais; 10- Compreender o benef?cio de todos os equipamentos da ambul?ncia. Os m?ltiplos riscos e suas combina??es emergidas no estudo indicam a multifatoriedade de a??es a serem desenvolvidas e estimuladas, como a utiliza??o de passos para a seguran?a do paciente no atendimento pr?-hospitalar m?vel que contribui como subs?dio no gerenciamento de riscos, diminui??o de erros, incapacidades e morte

No description available.

Bakgrund: Sjuksköterskan inom ambulanssjukvården behöver hållas uppdaterad inom den medicinska och omvårdnadens utveckling. Detta då sjuksköterskans arbete inom ambulanssjukvården är ett omväxlande arbete, där varje dag är olik. Den komplexa vård och arbetsmiljön ställer därmed höga krav på både den enskilda sjuksköterskan, och på ambulansteamet. Detta då de ibland träffar på svårt sjuka patienter och ytterligare resurser behövs på plats för att lösa varierande situationer, något som även kan orsaka stress. Problemformulering: Att ställas inför en kritiskt sjuk patient och inse att ytterligare resurser krävs, är realitet för samtliga sjuksköterskor inom ambulanssjukvården. Att behöva vänta på assistans och samtidigt vårda en kritiskt sjuk patient är något som kan bygga på ytterligare stressfaktorer hos sjuksköterskorna. Då det är begränsat med forskning inom området, genomfördes denna studie. Syfte: Sjuksköterskans upplevelse av att invänta assistans med en kritiskt sjuk patient, inom ambulanssjukvården. Metod: Semistrukturerade intervjuer hölls med åtta sjuksköterskor. Deltagarna kom från tre olika ambulansområden inom Västra Götalandsregionen. Ambulansområdena var belagda i storstad, mindre stad och landsbygd. Intervjuerna analyserades med kvalitativ induktiv ansats. Resultat: Analys av upplevelsen att invänta assistans resulterade i tre kategorier, i form av “behov av kontroll”, “känna sig otillräcklig” och “känna sig otrygg”. Diskussion: Sjuksköterska inom ambulanssjukvården ställs inför känslomässiga utmaningar i väntan på assistans, med en kritisk sjukpatient. Känslan att vara otrygg och otillräcklig skapar en hög stress, som resulterar i att sjuksköterskan vill göra så mycket som möjligt för patienten, även om allt inte kan göras. Sjuksköterskan löper risk att drabbas av psykisk ohälsa, ångest och PTSD. / Background: Nurses in ambulance healthcare need to be kept up-to-date in medical and nursing developments. This is because the nurse's work in ambulance healthcare is varied work, where every day is different. The complex care and work environment therefore place high demands on both the individual nurse, but also on the ambulance team. This is because they sometimes encounter seriously ill patients and additional resources are needed on site to resolve varying situations, something that can also cause stress.  Problem formulation: Being faced with a critically ill patient and realizing that additional resources are required is a reality for all nurses in ambulance healthcare. Having to wait for assistance and at the same time care for a critically ill patient is something that can build on additional stress factors for the nurses. As there is limited research in the area, this study was conducted.  Purpose: The nurse's experience of waiting for assistance with a critically ill patient, within the ambulance service.  Method: Semi-structured interviews were held with eight nurses. The participants came from three different ambulance areas within the Västra Götaland region. The ambulance areas were covered in big cities, smaller cities, and rural areas. The interviews were analysed using a qualitative inductive approach.  Results: Analysis of the experience of waiting for assistance resulted in three categories, in the form of "need for control", "feeling inadequate" and "feeling insecure". Discussion: Nurses in the ambulance service face emotional challenges while waiting for assistance, with a critically ill patient. The feeling of being unsafe and inadequate creates a high stress, which results in the nurse wanting to do as much as possible for the patient, even if everything cannot be done. The nurse is at risk of mental illness, anxiety, and PTSD.

Bakgrund: Specialistsjuksköterskan i en prehospital miljö ställs inför utmaningar när en svår luftväg inte längre kan hanteras genom basal luftvägshantering. Denna situation kräver spetskompetens inom avancerad luftvägshantering och anestesi, samt särskilda hjälpmedel. Inom vissa regioner finns en prehospital förstärkningsenhet som har som uppgift att komplettera ordinarie verksamhet med spetskompetens när det finns behov av avancerad luftvägshantering. Syfte: Syftet med studien var att studera anestesisjuksköterskors strategier vid hantering av svår luftväg i en prehospital förstärkningsenhet. Metod: En kvalitativ studie med datainsamling via enkät tillämpades och analyserades med kritisk incident teknik (CIT). Sexton anestesisjuksköterskor i en prehospital förstärkningsenhet i Sverige besvarade enkäten. Resultat: Analysen ledde fram till fyra betydelsefulla strategier för att hantera en svår luftvägprehospitalt. Förberedelse i att ställas inför en svår luftväg, mental förberedelse på väg ut på larm, möjligheten att lägga upp en primär samt en sekundär plan tillsammans med kollegan och att våga agera direkt var strategier som identifierades för att hantera en svår luftvägprehospitalt. Detsamma gällde att ta beslut i tid, att flytta patienten så att omhändertagandet inte behövde anpassas i onödan av omständigheter som kanske gick att undvika, att skapa åtkomst och insyn till patientens luftväg och ha närhet till egen utrustning vid hantering av en svår luftväg. Kollegan, teamkänsla, kommunikation, igenkännande, förståelse för varandras uppdrag och kännedom om varandras arbetssätt och utrustning var framgångsfaktorer för att få ett bra och effektivt teamarbete runt den svårt sjuka patienten. Utrustning som normalt inte fanns i en akutambulans som videolaryngoskop, endotrakealtub förberedd med ledare, kapnograf och en bra sug var framgångsfaktorer för att hantera en svår luftväg prehospitalt. Slutsats: Resultatet kan komplettera specialistutbildningar och introduktionsutbildningar för att göra specialistsjuksköterskan bättre förberedd på luftvägshantering i en prehospital miljö. Kunskapen kan bidra till en större förståelse för hur den svåra luftvägen på olika sätt kan undvikas eller hanteras. Basal luftvägshantering skall ambulanssjuksköterskan behärska i sin akutambulans men för hantering av den svåra luftvägen behövs särskild spetskompetens, hjälpmedel och förmåga.

Objectifs: Etudier l'évolution de l'introduction du rôle de l'IPA et proposer des recommandations pour les études ultérieures.Méthodes: Une revue de la littérature française et internationale concernant l'IPA. Participation à un groupe de travail national concernant l'avancement de ce rôle et les réformes éducationnelles. Une étude rétrospective comparant la prise en charge de patients hypoglycémiques en milieu pré-hospitalier par infirmiers et physiciens. Un questionnaire étudiant les perceptions des premiers étudiants en cursus IPA.Résultats: Différents niveaux de transferts de compétence et de collaboration médecin/infirmière existent déjà en France. Dans l'étude rétrospective, la qualité de soin des infirmières a été similaire à celle des médecins. Dans l'étude sur l'IPA, la majorité des étudiants a indiqué que les autres infirmières et docteurs ne sont pas au courant du rôle de l'IPA, et que des barrières bloquent son développement.Conclusions: La création du rôle d'IPA et le développement de la formation des infirmières en France peuvent répondre aux défis de santé publique, telle l'incidence croissante des maladies chroniques et la pénurie de médecins. Les recommandations suivantes furent proposées pour le développement du rôle de l'IPA : définir et faire reconnaître le rôle de la pratique infirmière avancée et ses compétences, promouvoir le rôle plus largement dans les disciplines médicales, soutenir les efforts de communication entre l'état et les professionnels de santé, développer des programmes au niveau master et doctorat, et promouvoir des travaux de recherche infirmiers et interdisciplinaires. / Background: In the context of public health challenges and health care reforms in France, the evolving advanced practice nurse (APN) role may be a solution. Objectives: To study the introduction of the ANP role and provide evidence-based recommendations for future research.Methods: A review of the international and French APN literature was performed. Participation in a national task force concerned advancement of the role and education reforms. In a retrospective study, nurses and physicians were compared in the pre-hospital management of hypoglycemic patients. Finally, a survey was administered to the first French APN Master's students to identify their perceptions of the APN role.Results: Variables levels of skill transfer and doctor-nurse collaboration currently exist in France. In the retrospective study, the pre-hospital quality of care of nurses was comparable to that of doctors. In the APN student survey, the majority indicated that other nurses and doctors were not aware of the APN role, and that barriers exist in role development. Conclusions: Creation of the APN role and advancement of nursing education in France can respond to public health challenges including the rising incidence of chronic diseases and an impending physician shortage. The following recommendations were proposed for APN role development: to define and recognize the advanced practice nurse role and related competencies, promote the role in a wider range of medical disciplines, facilitate clear communication between government and health care professionals, develop nursing Master's and Doctorate programs, and promote nursing and interdisciplinary research.

Maternal mortality is a global health concern but inequalities in utilization of maternal health care are not clearly understood. Severe morbidity (near-miss) is receiving increased attention due to methodological difficulties in maternal mortality studies. The present thesis seeks to increase understanding of factors that impede utilization of emergency obstetric care (EmOC) in Bolivia and Guatemala. Studies I and IV employed qualitative interviews to explore the role of traditional birth attendants (TBAs) and the care-seeking behaviour of women who arrived at hospital with a near-miss complication. Studies II–III documented maternal mortality and near-miss morbidity at the hospital level and investigated the influence of socio-demographic factors and antenatal care (ANC) on near-miss upon arrival. The studies identified unfamiliarity with EmOC among TBAs and a lack of collaboration with formal care providers. A perception of being dissociated from the health care system and a mistrust of health care providers was common among near-miss women from disadvantaged social backgrounds. In the Bolivian setting, 187 maternal deaths per 100,000 live births and 50 cases of near-miss per 1000 were recorded. Causes of near-miss differed from those of maternal deaths. Most women with near-miss arrived at hospital in critical condition: severe preeclampsia, complications after childbirth at home and abortions were mostly encountered among them. Lack of ANC, low education, and rural residence were interactively associated with near-miss. ANC reduced socio-demographic differentials for near-miss. Complementing maternal mortality reviews with data on near-miss morbidity increases the understanding of priority needs and quality of maternal health care. Additionally, focusing on near-miss upon arrival was found useful in exploring pre-hospital barriers to EmOC. The findings identified subgroups of women who seemed especially vulnerable to pre-hospital barriers. They also underscored the need for initiatives to reduce the effect of social marginalization and to acknowledge the influential role of formal and informal care providers on the utilization of EmOC. / La mortalidad materna es un tema de inquietud global, sin embargo la comprensión de las desigualdades en la utilización de los servicios de salud materna es limitada. La morbilidad obstétrica severa (near-miss) está recibiendo creciente atención, producto de problemas metodológicos en los estudios de mortalidad materna. El objetivo de la presente tesis es aumentar la comprensión de factores que impiden la utilización de la atención obstétrica de emergencia en Bolivia y Guatemala. Los estudios I y IV usaron metodologías cualitativas en un esfuerzo por explorar el rol de las parteras tradicionales y las estrategias de las mujeres que arriban a los hospitales con una morbilidad obstétrica severa. Los estudios II–III documentaron la mortalidad materna y la morbilidad obstétrica severa en el marco hospitalario e investigaron el impacto de los factores socio-demográficos y el control prenatal en la llegada a los establecimientos de salud con complicaciones severas. Los estudios identificaron la falta de familiaridad con atención obstétrica de emergencia entre las parteras tradicionales y la falta de cooperación con los profesionales de salud formales. La sensación de estar distanciadas del sistema de salud y la desconfianza hacia los profesionales de la salud eran aspectos comunes entre las mujeres de sectores marginales con experiencias de complicaciones severas. En el contexto boliviano, 187 muertes maternas por cada 100,000 nacidos vivos y 50 casos de morbilidad obstétrica severa por cada 1000 fueron registradas. Las causas de la morbilidad obstétrica severa y las muertes maternas se distinguieron. La major parte de las mujeres con morbilidad obstétrica severa llegaron al hospital en condiciones críticas: preeclampsia severa, complicaciones después de partos domiciliarios y abortos eran causas más frecuentes en esta categoría. Combinaciones del bajo nivel de educación con la falta de controles prenatales o la residencia en zonas rurales fueron asociadas con la morbilidad obstétrica severa. El control prenatal redujo diferencias socio-demográficas en lo concerniente a la morbilidad obstétrica severa. La complementación de estudios de mortalidad materna con datos sobre morbilidad obstétrica severa aumenta la comprensión de las prioridades y de la calidad en la atención de la salud materna. Además, centrándose en la morbilidad obstétrica severa a la llegada al establicimiento de salud, ha sido útil para investigar las barreras pre-hospitalarias en relación a la atención de emergencia obstétrica. Los resultados permiten identificar categorías específicas de mujeres que parecen ser especialmente vulnerables a las barreras pre-hospitalarias. Los resultados, también subrayan la necesidad de iniciativas que reduzcan los efectos de la marginalización social, y que reconozcan el importante rol que tanto el personal de salud formal como informal cumplen en la utilización de los servicios de atención obstétrica de emergencia.

L'engorgement des services des urgences est une question d'actualité. L'augmentation de la fréquentation de ces services par des cas non urgents surcharge ces centres de soins. Par conséquence, la qualité du service délivré aux patients se dégrade et les coûts des soins augmentent. Afin de résoudre ce problème, cette étude porte un intérêt particulier au réseau amont de prise en charge des urgences (pompiers, ambulances privées,médecin libéral, SAMU…). Il s'agit de savoir comment le dispositif actuel doit s'adapter afin de mieux répondre aux besoins des patients. Pour ce faire, le champ de l'étude s'est réparti en deux parties.Une première analyse s'est focalisée notamment sur la régulation médicale au SAMU/Centre15, pivot du réseau amont de prise en charge des urgences et ciment des relations entres les différents acteurs des urgences hospitalières.Une deuxième partie, à vision se situant à un niveau plus global cette fois, prend en compte la phase amont de la prise en charge des urgences dans sa totalité. Elle analyse la complexité du réseau et se centre sur deux éléments d'amélioration possibles, celui de l'introduction des Maisons Médicales de Garde et celui du renforcement de SOS Médecins. / Emergency Department (ED) overcrowding is a topical issue. The increasing attendance at such service by patients with non urgent problems resulted in surcharging the ED. Consequently, the quality of the delivered service is degraded and the care costs are on the increase. In order to solve this problem, a particular interest is taken in the pre-hospital emergency care network (firemen, private ambulances, General Practitioner, SAMU…). Our main purpose is to determine how the current system must adapt to better respond to patients health care needs. This study is divided into two parts: A first analysis focuses on the processing of emergency calls into the SAMU/Centre 15 as itplays an important role in the management of patients flew through this network and guarantees better relations between different actors of this system.A second one deals with the entire pre-hospital emergency care network. The complexity ofthis net is analysed and some alternatives are studied in order to improve the management ofEmergency Department's patients: the establishment of « Maisons Médicales de Garde » and the strengthening of existing medical centres such as « SOS Médecins ».