Emergency Department Crowding. Objective Modelling based on Workload

Emergency Departments (ED) have a central role in modern healthcare, providing emergent care regardless of complaint 24/7. However, EDs are often characterized by long waiting times for patients and a stressful working environment for staff. These are features or a resource and demand mismatch, internationally known as ED crowding. Although several reports and news articles have indicated that ED crowding is a problem in Sweden, there is no systematic work to assess it, nor a validated method to measure it. These things are essential to understand both the severity and extent of the problem, and to evaluate initiatives to alleviate crowding. With this thesis, I aim to begin this process by looking at different aspects of crowding assessment.The thesis is built upon four studies, each providing a different perspective on how to measure ED crowding. In the first paper we derived a model that can measure crowding, defined by ED staff, based on data from the digital information system in the ED. The model was derived in 5 EDs in the county of Skåne in Sweden and validated in 2 of these EDs. We propose a model that includes the number of patients in the ED, their waiting times and acuity, and that shows promising ability to measure crowding both in the derivation and validation; The Skåne Emergency Department Assessment of Patient Load (SEAL) model. Paper II investigates the prevalence of crowding and boarding, ie when patients are waiting for an inhospital bed in the ED, on a national level in Sweden. The results suggest that crowding is prevalent on a national level in Sweden, with 37% of the survey EDs reporting high occupancy rate during the 24 hour study period. Based on the data collected in paper II, the third paper in the thesis explores the relation between crowding, assessed by staff, and the ratio of patients to treatment beds, also known as the Occupancy Rate. The analysis in paper III indicates that high occupancy rates may not predict crowding as assessed by staff equally between EDs, and that crowding may be influenced by the organisation of the ED. This highlights the importance of systematic measurements of crowding adjusted for ED-specific features, like number of treatment beds. The last paper in the thesis examines the association between crowding and mortality. The results indicate an association between high levels of crowding, measured by a modified SEAL model, and an increased 7-day mortality, confirming that ED crowding is a real threat to the safety of our patients.This thesis indicates that ED crowding is prevalent on a national level in Sweden and associated with increased mortality for our patients. We would therefore strongly encourage a systematic assessment of crowding as an essential part of the regular quality insurance work, both locally and on a national level. Given the complexity of both crowding and the care in the ED, the assessment should likely include multiple different measures. We suggest using the modified SEAL model since it is a validated measure of crowding with good predictive value and an ability to identify situations where crowding is associated with increased mortality. Further studies should focus on predicting imminent crowding and on methods to reduce its impact on patients and staff

Aerospace Medicine and Biology: a Continuing Bibliography with Indexes (Supplement 328)

This bibliography lists 104 reports, articles and other documents introduced into the NASA Scientific and Technical Information System during September, 1989. Subject coverage includes: aerospace medicine and psychology, life support systems and controlled environments, safety equipment, exobiology and extraterrestrial life, and flight crew behavior and performance

In-reach specialist nursing teams for residential care homes : uptake of services, impact on care provision and cost-effectiveness

Background: A joint NHS-Local Authority initiative in England designed to provide a dedicated nursing and physiotherapy in-reach team (IRT) to four residential care homes has been evaluated.The IRT supported 131 residents and maintained 15 'virtual' beds for specialist nursing in these care homes. Methods: Data captured prospectively (July 2005 to June 2007) included: numbers of referrals; reason for referral; outcome (e.g. admission to IRT bed, short-term IRT support); length of stay in IRT; prevented hospital admissions; early hospital discharges; avoided nursing home transfers; and detection of unrecognised illnesses. An economic analysis was undertaken. Results: 733 referrals were made during the 2 years (range 0.5 to 13.0 per resident per annum)resulting in a total of 6,528 visits. Two thirds of referrals aimed at maintaining the resident's independence in the care home. According to expert panel assessment, 197 hospital admissions were averted over the period; 20 early discharges facilitated; and 28 resident transfers to a nursing home prevented. Detection of previously unrecognised illnesses accounted for a high number of visits. Investment in IRT equalled £44.38 per resident per week. Savings through reduced hospital admissions, early discharges, delayed transfers to nursing homes, and identification of previously unrecognised illnesses are conservatively estimated to produce a final reduction in care cost of £6.33 per resident per week. A sensitivity analysis indicates this figure might range from a weekly overall saving of £36.90 per resident to a 'worst case' estimate of £2.70 extra expenditure per resident per week. Evaluation early in implementation may underestimate some cost-saving activities and greater savings may emerge over a longer time period. Similarly, IRT costs may reduce over time due to the potential for refinement of team without major loss in effectiveness. Conclusion: Introduction of a specialist nursing in-reach team for residential homes is at least cost neutral and, in all probability, cost saving. Further benefits include development of new skills in the care home workforce and enhanced quality of care. Residents are enabled to stay in familiar surroundings rather than unnecessarily spending time in hospital or being transferred to a higher dependency nursing home setting

Exploring the Differences in Autonomy for Residents with Alzheimer\u27s Disease Between Those Living in a Special Care Unit and Those in a Residential Group Home: A Comparative Study

Dementia of the Alzheimer\u27s type (DAT) is a progressive, terminal disease marked by the loss of cognitive function. Due to cognitive impairments, residents with dementia exhibit behaviors that indicate disordered person in environment transactions. Due to the resulting disordered transactions, residents with dementia living in long-term care settings offen experience diminished opportunity to choose. This paper is a comparative/descriptive study based on nursing assistant responses from an anonymous questionnaire in two long-term care facilities. Autonomy is defined by Callopy (1988) as freedom, independence and choice. The results indicate that the residents at each respective facility seem to experience autonomy in different areas, but that overall the level achieved is fairly consistent between the two. Both homes restrict autonomy, but it seems to be overshadowed by the enforcement of safety

Prevelance and determinants of diagnostic and prognostic disclosure by radiotherapists and surgeons to patients with terminal cancer in Hong Kong

This paper identifies the prevalence and determinants of diagnostic and prognostic information given to terminally ill cancer patients in Hong Kong. Surgeons and radiotherapists (n = 153) were interviewed about the information they gave to their most recently deceased cancer patients. This was explored in relation to doctors' and patients' demographic data, diagnosis, the stage of disease at disclosure, and doctors' attitude. Diagnostic information was disclosed partially in 68% and fully in 46% of cases. Prognosis was disclosed partially in 38% and fully in less than 10% of cases. Determinants of diagnostic disclosure included doctors' attitudes about death, and perceived responsibility for disclosure. The doctor's training and work, and the patient's request for information determined the level of disclosure. After adjustment for a number of social and demographic factors, only the patient's education level remained a significant determinant of the level of prognostic disclosure. A significant proportion of terminally-ill cancer patients do not engage in discussion of diagnosis or prognosis with the doctor caring for them during the last stages of their disease. This reflects the unwillingness to discuss such matters, giving a low priority to information provision, paternalism or other factors, such as little importance being attached to such topics at the late stage of cancer. Thus many cancer patients may fail to learn important information about their disease if they have not engaged in discussion of these topics earlier in their illness. The results of this paper have important implications for medical education in caring for patients with cancer.published_or_final_versio

Staff training on choice availability and its effects on adaptive and maladaptive behavior in persons with developmental disabilities in the group home setting

Recent research regarding persons with developmental disabilities has focused on the effects of choice availability on adaptive and maladaptive behavior. Because degree of choice within one\u27s living environment is considered a key element of quality of life, it seems important to evaluate this variable and its relationship to adaptive and maladaptive behavior. In this preliminary study, direct-care staff members in a group-home setting were taught to increase choice opportunities in the areas of eating, leisure, and personal hygiene for residents with mild, moderate, or severe mental retardation. This investigation also examined the effects of increased choice availability on residents\u27 adaptive and maladaptive behaviors. Increased staff training on choice availability was expected to result in improved choice and changes in levels of adaptive and maladaptive behavior for such residents. Results indicated that direct-care staff members who received training to increase choice reported increased choice opportunities for their residents. Increased choice, however, did not lead to improved levels of adaptive and maladaptive behavior for treatment group residents

Forecasting ward-level bed requirements to aid pandemic resource planning: Lessons learned and future directions

During the COVID-19 pandemic, there has been considerable research on how regional and country-level forecasting can be used to anticipate required hospital resources. We add to and build on this work by focusing on ward-level forecasting and planning tools for hospital staff during the pandemic. We present an assessment, validation, and deployment of a working prototype forecasting tool used within a modified Traffic Control Bundling (TCB) protocol for resource planning during the pandemic. We compare statistical and machine learning forecasting methods and their accuracy at one of the largest hospitals (Vancouver General Hospital) in Canada against a medium-sized hospital (St. Paul's Hospital) in Vancouver, Canada through the first three waves of the COVID-19 pandemic in the province of British Columbia. Our results confirm that traditional statistical and machine learning (ML) forecasting methods can provide valuable ward-level forecasting to aid in decision-making for pandemic resource planning. Using point forecasts with upper 95% prediction intervals, such forecasting methods would have provided better accuracy in anticipating required beds on COVID-19 hospital units than ward-level capacity decisions made by hospital staff. We have integrated our methodology into a publicly available online tool that operationalizes ward-level forecasting to aid with capacity planning decisions. Importantly, hospital staff can use this tool to translate forecasts into better patient care, less burnout, and improved planning for all hospital resources during pandemics

Getting to Zero Preventable Falls: An Exploratory Study

Objective: The objective of this study is to examine relations between patient safety culture and processes of care, specifically, how patient safety culture influences the prevention of patient falls. The purpose of this inquiry is to identify the barriers and facilitators that can advance an inpatient rehabilitation facility to become a high reliability organization and advance interdisciplinary teamwork. Method: A qualitative phenomenological approach was conducted and an interpretive phenomenological analysis explored the experiences of frontline staff with regard to patient safety culture and fall prevention. The study utilized semi-structured interviews with 24 frontline staff from three inpatient rehabilitation hospitals. Participants were selected using purposive sampling and individually interviewed. Results: Findings revealed barriers and facilitators for each dimension of patient safety culture that drive fall prevention. Teamwork within and across disciplines, such as between nursing and therapy, affect how they communicate with one another. Issues related to staffing were the most common concerns amongst nursing staff; especially the issue of staffing ratio and patient acuity. Leadership played a role in supporting the culture of safety and holding staff accountable. Conclusion: Fall prevention requires collaborative efforts between nursing and therapy in an inpatient rehabilitation setting. Dimensions of patient safety culture such as good teamwork, effective communication, adequate staffing, nonpunitive response to errors, and strong leadership support are essential in maintaining a high reliability process for adaptive learning and reliable performance

Staff Education for Identifying, Assessing and Managing Pain in Patients with Dementia

Pain is a common symptom in healthcare settings, especially among patients with Alzheimer\u27s Disease (AD). AD patients have cognitive and communication impairment making it difficult or impossible for them to communicate their pain to their caregivers or healthcare practitioners. The purpose of this project was to implement a staff education program for healthcare professionals on evidence-based practices for assessing, recognizing, and managing pain in patients with AD. The practice-focused question explored if a staff education program on identification, assessment, and management of pain in patients with AD improves the staff\u27s knowledge, skills, and attitude towards timely and effective pain assessment management. This project was implemented in a 50-bed nursing home. Fourteen healthcare staff participated in the education program. Data on the participants’ skills, knowledge, and attitudes in assessing, caring, and managing pain in patients with AD were measured using the knowledge and attitude survey regarding pain (KASRP) tool. The KASRP score following the execution of the staff education program indicated an improvement in all areas. The mean score on the pretest was 28 (71.79% correct) and the mean score on the posttest 35 (89.74% correct). There was a significant difference in the score on the KASRP pretest (m = 28, SD = 4.772) and the KASRP tool posttest (m = 35, SD = 2.680) conditions, t(27) = -12.11, p = .05. These results suggest that training health workers on recognizing, identifying, assessing, and managing pain in patients with AD can enhance their skills, knowledge, and positive attitude in assessing and treating pain in this patient population and promote positive social change for patients, families, and caregivers